2002/154/EC: Decision No 179 of 18 April 2000 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111, E 111 B, E 113 to E 118 and E 125 to E 127) (Text with EEA relevance)
25. 2. 2002 EN Official Journal of the European Communities L 54/1 II (Acts whose publication is not obligatory) COMMISSION THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS DECISION No 179 of 18 April 2000 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111, E 111 B, E 113 to E 118 and E 125 to E 127) (Text with EEA relevance) (2002/154/EC) THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS, Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their family moving within the Community (1), under which it the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations, is the duty of Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 (2) fixing the procedure for implementing Regulation (EEC) No 1408/71, under which it the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the application of the Regulations, the duty of is Having regard to Council Regulation (EC) No 1606/98 (3) amending Regulations (EEC) No 1408/71 and (EEC) No 547/72 with a view to extending them to cover special schemes for civil servants, Having regard to Council Regulation (EC) No 307/1999 (4) amending Regulations (EEC) No 1408/71 and (EEC) No 547/72 with a view to extending them to cover students, Whereas it is necessary to amend Decisions No 153 (5) and No 168 (6) concerning the model forms necessary for the application of the Regulations; Whereas these model forms should also be adapted for the purpose of taking account of the amendments which have been introduced into the national legislation of Member States; (1) OJ L 149, 5. 7. 1971, p. 2. (2) OJ L 74, 27. 3. 1972, p. 1. (3) OJ L 209, 25. 7. 1998, p. 1. (4) OJ L 38, 12. 2. 1999, p. 1. (5) OJ L 244, 19. 9. 1994, p. 22. (6) OJ L 195, 11. 7. 1998, p. 37. L 54/2 EN Official Journal of the European Communities 25. 2. 2002 Whereas the Agreement on the European Economic Area of 2 May 1992, supplemented by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area; Whereas, by Decision of the EEA Joint Committee, the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 will be adapted and used within the European Economic Area; Whereas, for practical reasons, identical forms should be used within the Community and within the European Economic Area; Whereas the language in which the forms should be issued is the subject of Recommendation No 15 of the Administrative Commission, HAS DECIDED AS FOLLOWS: 1. The model forms E 111, E 111 B, E 113 to E 118, E 125 and E 126 reproduced in Decision No 153 and E 127 reproduced in Decision No 168 shall be replaced by the models appended hereto. 2. The competent authorities of the Member States shall make available to the parties concerned (rightful claimants, institutions, employers, etc. ) the forms according to the models appended hereto. 3. Each form shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all addressees (rightful claimants, institutions, employers, etc. ) to receive the form printed in their own language. 4. This Decision shall be applicable from the first day of the month following its publication in the Official Journal of the European Communities. The Chairman of the Administrative Commission Sebastiªo PINTO PIZARRO EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 2 and 3. 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. a; Art. 22. 3; Art. 31. a; Art. 34. a Reg. 574/72:Art. 20. 4; Art. 21. 1; Art. 23; Art. 31. 1 and3 n Employed person n Pensioner (scheme for employed persons) n Student 1 n Self-employed person n Pensioner (scheme for self-employed persons) n Other insured person (Surname (1a), Previous names (1a), D. N. I. (2a), Address) 1. 1 Identification No (2b). Date of birth. 2 Members of the family (3) 2. 1 Surname (1a) Forenames Previous names Date of birth Identification No (2b). 2. 2 Permanent address (2) (4). 3 The above-named persons are entitled to benefits in kind under sickness and maternity insurance. These benefits may be provided (5) n from (5) n from 3. 1 3. 2. to. inclusive. a E 111 4 Competent institution 4. 1 4. 2 Name Address (2). Code number (6). 4. 3 Stamp 4. 4 4. 5 Date. Signature. 4. 6 4. 7 5 5. 1 5. 2 Valid from. to. Stamp 4. 8 Date 4. 10 4. 11 Valid from. to. Stamp 4. 12 Date. 4. 9 Signature 4. 13 Signature. Competent French institution for non-occupational accidents sustained by self-employed farmers Name Address (2). Code number (6). 5. 3 Stamp 5. 4 5. 5 Date. 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. The competent institution or, where appropriate, the institution in the place of residence of the pensioner, or the member of the family of the worker should complete this form and send it to the person concerned, or send it to the institution in the place of stay if the form has been drawn up at the latter's request. This form is not requiredif the personconcernedis staying in the UnitedKingdom. Information for the insured person and the members of his family (a) The document enables: — in the case of immediate need the employed or self-employed person, student or other insured person and the members of his family named in Section2 who arestayingtemporarilyin a Member State other than the competent State, and — the pensioner and the members of his family, named in box 2 who are staying temporarily in a Member State other than that in which they habituallyreside, to obtainbenefits in kind from insurancebodiesin the country of stay, in the case of sickness, chronicdiseases or maternity and, provisionally, in the case of an accident at work or occupational disease. However this document does not provide entitlement to benefits in kind if the aim of the journey is to receive medicaltreatment abroad. (b) When one of the persons concerned has to seek benefits, including hospitalisation, he should submit this form to the insurance body in the country in which heis staying, i. e. : in Belgium, the ‘mutualité’(local sickness insurancefund) 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 institution. This form must be submitted for each claim for benefits. Particulars about doctors and dentists availablemay be obtainedfrom the local‘social- ogsundhedsforvaltning’(social andhealth authority); in Germany, the sickness fund chosenby the personconcerned; in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a ‘health book’, without whichno benefits inkind can be provided; b E 111 in Spain, the medical andhospitalservices of the SpanishSocial Security health system. The form must be submitted, togetherwith a photocopy; in France, the ‘Caisseprimaired'assurance-maladie’(localsickness insurancefund); in Ireland, the Health Boardin whosearea the benefitis claimed; in Italy, the ‘Unità sanitaria locale’ (USL, the local health administration unit) responsible for the area concerned; for mariners and for civilian aircrews, the ‘Ministero dellasanità, Ufficio di sanitàmarrittima o aerea’ (Ministry of Health, the navy or aviation health office responsible for the area in question); in Luxembourg, the ‘Caissedemaladiedes ouvriers’; in the Netherlands, the ANOZ Verzekeringen, Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ Verzekeringen if a person has to enter hospital, the admittance Form and Form E 111 will be sent by the hospital to ANOZ Verzekeringen; in Austria, the ‘Gebietskrankenkasse’ (Regional Fundfor Sickness Insurance); in Portugal, for metropolitan Portugal: the ‘Administração Regional de Saúde’ (Regional Health Administration) of the place of stay; for Madeira: the ‘Direcção Regional de Saúde Pública’ (Regional Public Health Directorate) in Funchal; for the Azores: the ‘Direcção Regional de Saúde’ (RegionalHealth Directorate) in Angrado Heroísmo. in Finland, the local office of the ‘kansaneläkelaitos’ (Social Insurance Institution), if compensation is sought for medical expenses incurred in the private sector. Benefits in kind can beobtainedfrommunicipalhealth centres and publichospitals by presenting thecertificate; in Sweden, the ‘försäkringskassan’ (Social Insurance Office). Assistance from the medical service (hospital, doctor, dentist, etc. ) may be sought without first contactingthe said institution; in Iceland, the ‘Tryggingastofnun rikisins’(State SocialSecurity Institute), Reykjavik; in Liechtenstein, the ‘Amt für Volkswirtschaft’ (Office of NationalEconomy), Vaduz; in Norway, the ‘lokale trygdekontor’ (local Insurance Office). Assistance from the medical service may be sought without first contacting the institutionmentioned. This form shouldbe presentedwhenassistance is sought. (c) In order to receive cash benefits the person concerned shall, within three days of commencement of the incapacity for work, apply to the institution of the place of stay by submitting a notification of having ceased work or, if the legislation administered by the competent institution or by the institution of the placeof stay so provides,a certificate of incapacity for work issuedby the doctor providingtreatmentfor theperson concerned. NOTES * (1) (1a) (2) (2a) (2b) (3) (4) (5) (6) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. Street, number, post code, town, country. In the case of Spanish nationals state the number appearing on the national identy card (D. N. I. ), if it exists, even if the card is out of date. For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. Include only those members of the family who are temporarily going to another Member State. Complete only if the address of the members of the family differs from that of the worker or pensioner. These two items are mutually exclusive. Give only that which is applicable and put a cross in the corresponding box. To be completed where this exists. c EUROPEAN COMMUNITIES Social Security Regulations EEA* SCHEME FOR SELF-EMPLOYED PERSONS See ‘Instructions’ overleaf E 111 B (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. 574/72:Art. 20. 4; Art. 21. 1; Art. 23; Art. 31. 1 and3 n Self-employed person n Pensioner 1 (Surname (1a), Previous names (1a), forenames, address (2)) 1. 1 Identification No (1b):. Date of birth. 2 Members of the family (3) 2. 1 Surname (1a) Forenames Previous names Date of birth Identification No (1b). Y L. N O. A. N TIO. 2. 2 Permanent address (2) (4):. 3 The above-named persons are entitled to benefits in kind in the case of hospitalisation only. These benefits may be provided 3. 1 from. to. inclusive 4 Competent institution 4. 1 4. 2 Name Address (2):. Code number (5):. 4. 3 Stamp 4. 4 4. 5 Date. Signature. 4. 6 4. 7 Valid from. to. Stamp 4. 8 Date 4. 10 4. 11 Valid from. to. Stamp 4. 12 Date. 4. 9 Signature 4. 13 Signature. a. A LIS PIT S O H R O F SCHEME FOR SELF-EMPLOYED PERSONS E 111 B 4. 14 4. 15 Valid from. to. Stamp 4. 16 Date 4. 18 4. 19 Valid from. to. Stamp 4. 20 Date. 4. 17 Signature 4. 21 Signature. Please complete this form in block letters, writing on the dotted lines only. INSTRUCTIONS The competent institution or, where appropriate, the institution in the place of residence of the pensioner, should complete this form and send it to the person concerned, or send it to the institution in the place of stay if the form has been drawn up at the latter's request. This form is not required if the personconcernedis staying in the UnitedKingdom. Information for the insured person and the members of his family (a) This document enables: — the self-employed person and the members of his family named in box 2, who are staying temporarily in a Member State other than the competent State, and — the pensioner covered by the scheme for the self-employed and the members of his family named in box 2, who are staying temporarily in a Member State other thanthat in which they habituallyreside, to obtain benefitsin kind from insurancebodiesin the country of stayonly in the case of hospitalisation. (b) When one of the persons concerned has to enter hospital, he should submit this form to the insurance body in the country in which he is staying, i. e. : 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). Thisform must be submitted for eachclaim for benefits; in Germany, the sickness fund chosenby the personconcerned; in Greece, the regional or local branch of the Social Insurance Institute (IKA) which issues the person concerned with a ‘health book’ without which no benefits canbe provided; in Spain, the hospital services providedunder thesocial security scheme. The form must be submitted, together with a photocopy; in France, the ‘Caisseprimaired'assurance-maladie’(localsickness insurancefund); in Ireland, the Health Boardin whosearea the benefitis claimed; in Italy, the ‘Unitá sanitarialocale’(USL, the localhealth administrationunit) responsiblefor the areaconcerned; in Luxembourg, the ‘Caissedemaladiedes ouvriers’(sickness fundfor manual workers); in the Netherlands, the ‘ANOZ-Verzekeringen',Utrecht;’ in Austria, the ‘Gebietskrankenkasse’ (Regional Fundfor Sickness Insurance) competent for yourplace of stay; in Portugal, for metropolitan Portugal: the ‘Administração Regional de Saúde’ (Regional Health Administration of the place of stay); for Madeira: the ‘Direcção Regional de Saúde Pública’ (Regional Public Health Directorate) in Funchal; for the Azores: the ‘Direcção Regional de Saúde’ (RegionalHealth Directorate) in Angrado Heroísmo; in Finland, the local office of the ‘Kansaneläkelaitos’ (social insurance Institution) and the hospital providing treatment. This form must be submitted with each claimfor benefits; in Sweden, the ‘försäkringskassan’(Social InsuranceOffice) at the place of stay; in Iceland, the ‘Tryggingastofnun rikisins’(the State SocialSecurity Institution), Reykjavik; in Liechtenstein, the ‘Amt für Volkswirtschaft’ (the Office of NationalEconomy), Vaduz; in Norway, the ‘lokaletrygdekontor’ (the localInsurance Office) at the placeof stay. NOTES (*) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. (1) Symbol of the country to which the institution completing the form belongs: B = Belgium. (1a) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (1b) For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale'. ’ (2) Street, number, post code, town, country. (3) Include only those members of the family who are temporarily going to another Member State. (4) Complete only if the address of the members of the family differs from that of the insured person or pensioner. (5) To be completed where this exists. b EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 2 E 113 (1) HOSPITALISATION: NOTIFICATION OF ENTERING AND LEAVING HOSPITAL Reg. 1408/71:Art. 19;Art. 22; Art. 22. a; Art. 22. b; Art 25. 1 and3. i; Art. 26;Art. 31. a; Art. 34. a; Art. 34. b; Art. 52. a; Art. 55. 1 Reg. 574/72: Art. 17. 6; Art. 20. 5; Art. 21. 2; Art. 22. 2 and3; Art. 23; Art. 26. 3; Art. 27; Art. 28; Art. 31. 2and 3; Art. 60. 5; Art. 62. 7; Art. 63. 2 This form should be drawn up in the event of a refund of benefits in kind on the basis of actual expenditure. It should be completed by the institution in the place of residence or stay: part A to notify entry into hospital, part B to notify discharge from hospital. It should be sent to the competent institution. If the competent institution is aninstitution in Denmarkor the UnitedKingdom, this form is not required. 1 Competent institution 1. 1 1. 2 Name Address (2):. n Employed person n Pensioner (scheme for employed persons) n Student 2 n Self-employed person n Pensioner (scheme for self-employed persons) n Other insured person n Unemployed person n Pension claimant 2. 1 Surname (2a). 2. 2 Forenames Previous names (2a) Date of birth. 2. 3 Address in the country of residence or stay (2). 2. 4 Identification No (2b). 3 Member of the family who is in hospital 3. 1 Surname (2a). 3. 2 Forenames Previous names Date of birth. 3. 3 Address in the country of residence or stay (2) (3). 3. 4 Identification No (2b). Reference: 4 4. 1 n your form 4. 2 n our E 107 form of A. Notification of entry into hospital. of. (4). 5 5. 1 5. 2 5. 3 The person mentioned entered hospital on namely (5) because of n in box 2 n in box 3. (date). n sickness n on occupational disease (7) n maternity n an accident in private life (8) n an accident at work (6) He/she will probably stay in hospital until 5. 4 5. 5 n (9) Supporting documents or medical report attached. a E 113 B. Notification of discharge from hospital 6 The hospitalisation notified n by our E 113 form dated n in part A above ended on. 7 Institution in the place of residence or stay. 7. 1 7. 2 Name Address (2). 7. 3 Stamp 7. 4 7. 5 Date Signature. Please complete this form in block letters, writing on the dotted lines only. INSTRUCTIONS NOTES * (1) (2) (2a) (2b) (3) (4) (5) (6) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein, N = Norway. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. In the case of Spanish nationals state the number appearing on the national identity card (D. N. I. ), if it exists, even if the identity card is out of date, or passport/N. I. F. For Italian nationals indicate, if possible, the insurance and/or the ‘code fiscale’. For persons insured in Sweden enter national personal identification number. To be indicated if the address of the member of the family is different from that mentioned in box 2. Number and date of issue of the form certifying the insured person's entitlement to benefits. Name of hospital. If the patient is insured in Belgium or Liechtenstein, indicate in the box below the name and address of the employer. Name of employer or firm. Address (2). Indicate if possible. To be completed for French institutions for self-employed agricultural workers and for Portuguese institutions. (7) (8) (9) Where appropriate, put a cross in this square. b EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 2 E 114 (1) GRANTING OF MAJOR BENEFITS IN KIND Reg. 1408/71:Art. 19; Art. 22;Art. 22. a; Art. 22. b; Art. 24; Art. 25. 1 and3. i; Art. 26; Art. 31. a; Art. 34. a; Art. 34. b; Art. 52. a; Art. 55. 1 Reg. 574/72: Art. 17. 7; Art. 20. 5; Art. 21. 2; Art. 22. 2 and3; Art. 23; Art. 26. 3; Art. 27; Art. 28;Art. 31. 2and 3; Art. 60. 6; Art. 62. 7; Art. 63. 2and 3 This form should be drawn up in the event of a refund of benefits in kind on the basis of actual expenditure. The institution in 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 in item 7. 1 or 7. 2. If the competent institution decides that it must oppose the granting of benefits, it should complete part B and return a copy of the form to the institution in 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 1. 2 Name Address (2). 2 (3) n Employed person n Pensioner n Student n Self-employed person n Pensioner n Other insured person (scheme for employed persons) n Unemployed person n Pension claimant (scheme for self-employed persons) 2. 1 Surname (3a). 2. 2 Forenames Previous names (3a) Date of birth. 2. 3 Address in the country of residence or stay (2). 2. 4 Identification No (3b). 3 Member of the family concerned 3. 1 Surname (3a). 3. 2 Forenames Previous names Date of birth. 3. 3 Address in the country of residence or stay (2) (4). 3. 4 Identification No (3b). Reference 4 4. 1 n your form 4. 2 n our E 107 form of 5 Our medical service has recognised, for the person mentioned n in box 2 5. 1 n the necessity 5. 2 n in box 3 n the extreme urgency of the following benefits. of. (5). (date). 5. 3 the n probable n actual costs of which are within the meaning of our legislation. (6) 6 n Please find attached the report from our examining doctor (7) The benefits mentioned in item 5. 2 (8) 7 7. 1 n have already been provided in view of the urgent nature of the case, on 7. 2 n will be provided unless we receive any reasons for objection on your part within 15 days of the date of dispatch of this notification. a E 114 8 Institution in the place of residence or stay 8. 1 8. 2 Name Address (2). 8. 3 Stamp 8. 4 8. 5 Date Signature. B. Reasons for objection on the part of the competent institution, if any 9 With reference to item 7. 2 above, we hereby inform you that the benefits indicated in item 5. 2 cannot be granted Reason. 10 Competent institution 10. 1 10. 2 Name Address (2):. Code number (9). 10. 3 Stamp 10. 4 10. 5 Date Signature. Please complete this form in block letters, writing on the dotted lines only. INSTRUCTIONS NOTES * (1) (2) (3) EEA Agreement on the European Economic Area, Annex VI, social security for the purpose of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. Street, number, post code, town, country. If the patient is insured in Belgium or Liechtenstein, give name and address of employer in the box below: Name of employer or firm. Address (2). (3a) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. Indicate only if the address of the member of the family is different from that mentioned in box 2. Number and date of issue of the form certifying that the person concerned is entitled to benefits. The cost should be indicated in the currency of the country of stay or residence. If the medical report is attached to the form, put a cross in the square provided. (3b) (4) (5) (6) (7) (8) Where the person concerned is a self-employed Belgian take into account only benefits in kind in the event of hospitalisation. (9) To be completed where this exists. b EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 3 E 115 (1) CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORK Reg. 1408/71: Art. 19. 1. b; Art. 22. 1. a. ii; Art. 22. b; Art. 25. 1. b. ; Art. 34. b; Art. 52. b; Art. 55. 1. a. ii Reg. 574/72: Art. 18. 2 and 3; Art. 24; Art. 26. 5 and7; Art. 61. 2 and3; Art. 64 If the form is drawn up for an insured person in active employment, one copy only should be completed and sent to the institution competent as regards sickness and maternity insurance or as regards an insurance against accidents at work and occupational diseases. However, if it concerns an unemployed person, two additional copies should be drawn up, one of which should be sent to the institution competent in unemployment insurance, the other to the correspondinginstitution inthe country to whichthe unemployedpersonhas gone to seekemployment (seealso notes 7 and9). 1 Competent institution 1. 1 1. 2 Name Address (2). 2 2. 1 n Employed person n Self-employed person n Unemployed person Surname (2a). 2. 2 Forenames Previous names (2a) Date of birth 2. 3 2. 4 2. 5 2. 6. Address in the competent country (2). Address in the country of residence or stay (2). Identification No (2b) holds an E 119 form issued on and an E 303 form issued on. (3) (3) 3 Employer (4) 3. 1 3. 2 Name of employer or firm Address (2). 3. 3 Nature of business. A. n (5) Claim for benefits 4 The person mentioned in box 2 applied on. (date) for cash benefits for incapacity for work due to 4. 1 n sickness (6) n accident at work n occupational disease n maternity (expected date of confinement n accident sustained on n adoption. n reduced compensation in case of maternity and (date). ) 5 The certificate of the doctor treating him/her n is attached n could not be supplied adoption (6) a 6 In the opinion of our examining doctor E 115 n whose report is attached n whose report will be sent to you as soon as possible 6. 1 n the incapacity for work began on and will probably continue until 6. 2 n there is no incapacity for work (7). 7 n The person concerned is deemed not to have complied with the provisions of our legislation for the following reasons:. n The incapacity for work was presumably caused by an accident for which a third party was responsible. 8 8. 1 n A report on this accident with the address of the third party involved is attached to this form. 9 n 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 (8). 10 n We are not willing to provide cash benefits to the person concerned on your behalf. B. n (5) Extension of the incapacity for work 11 With reference to 11. 1 n our E 115 form of 11. 2 n your E 117 form of 11. 3 we wish to inform you that, in the opinion of our examining doctor n whose report is attached n whose report will be sent to you as soon as possible the person mentioned in box 2 will probably remain incapable of work until. (date). (date). inclusive 12 Institution in the place of residence or stay 12. 1 12. 2 Name Address (2). 12. 3 Stamp 12. 4 12. 5 Date Signature. b 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. INSTRUCTIONS NOTES E 115 * (1) (2) (2a) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose or this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status they appear on the identity card or passport. For Italian nationals indicate if possible, the insurance number and/or the ‘codice fiscale’. Complete only if the form concerns an unemployed person. For unemployed persons, indicate the last employer. Complete either part A or part B and put a cross in the square corresponding to the part completed. For the Netherlands box 4 must be filled in. Please attach a copy of an E 118 form sent to the person concerned. If the form is being sent to a German or an Italian institution, this box need not be ticked, only box 10. In Italy you should submit this form — in case of sickness or maternity to the local office of the ‘Istituto nazionale della previdenza sociale’ (INPS, National Social Welfare Institute) — in case of an accident at work or occupational disease to the ‘Istituto nazionale assicurazione contro gli infortuni sul lavoro’ (INAIL). For the Netherlands if the competent sickness insurance institution is not known send the form to the G. A. X. , Postbus 8300 Amsterdam. (2b) (3) (4) (5) (6) When applying from Norway. (7) (8) (9) c EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 3 E 116 (1) 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; 1. b. ii; 1. c. ii; Art. 22. b; Art. 25. 1. b; Art. 34. b; Art. 52. b; Art. 55. 1. a. ii; 1. b. ii and 1. c. ii Reg. 574/72: Art. 18. 2 and3; Art. 24; Art. 26. 5 and7; Art. 61. 2 and 3; Art. 64; Art. 65. 2 and 4 To be completed by the doctor of the institution which draws up an E 115 form to be attached to that form and sent under sealed cover in the case of sickness or maternity. For Belgium, this form should always be sent first to the Belgian institution competent as regards sickness insurance (9). In Liechtenstein, Norwayand Swedenthe form is filled inby the doctor the personconcernedis visiting andverified bythe insuranceinstitution. 1 Competent institution to which the form is addressed 1. 1 1. 2 Name Address (2):. 1. 3 Reference: our E 116 form of. (date) 2 Attached to an E 115 form of. (date) 3 n Employed person n Self-employed person n Unemployed person 3. 1 Surname (2a). 3. 2 Forenames Previous names (2a) Date of birth. 3. 3 Address in the country of residence or stay (2). 3. 4 Identification No (3):. 4 I, the undersigned,. doctor of medicine, having examined the person mentioned above on. 4. 1 consider that it is n case of sickness that it is probably n an accident at work 4. 3 n a relapse or aggravation 4. 2 n case of maternity (expected date of confinement. ) n an occupational disease n an accident a E 116 A. General report 5 To be completed in every case, particularly in the case of an accident at work 5. 1 Medical history and present symptoms. 5. 2 5. 3 5. 4 Clinical examination General condition. Weight. Height. (4) Other observations. 5. 5 Special examinations (5):. 5. 6 Diagnosis. Conclusions 5. 7 5. 8 n The person concerned has not been found to be unfit for work 5. 9 n The person concerned has been found to be unfit for work from. to. 5. 10 n The person concerned has been found partly unfit for work to a degree of. % from. to. (5a) 5. 11 n The person concerned will be given a further medical examination on 5. 12 n The person concerned should be fit for work on. B. Reports in the case of an accident at work 6 First medical report 6. 1 This accident has resulted in the following injuries (6). 6. 2 These injuries n have had n will have the following effects (7). Incapacity for work began on. The injured person is being treated n at home n in hospital Address (2) (8): n at the doctor's surgery n elsewhere. 6. 3 6. 4 b E 116 7 Final medical report 7. 1 The treatment ended on. The injuries were consolidated on 7. 2 7. 3 n without after-effects 7. 4 n and will probably have the following consequences. 7. 5 Detailed description of the injured person's condition after recovery or at the end of the medical treatment. 8 Institution in the place of residence or stay 8. 1 8. 2 Name Address (2):. 8. 3 Stamp 8. 4 8. 5 Date. Doctor's signature. 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. INSTRUCTIONS NOTES * (1) (2) (2a) (3) (4) (5) (5a) (6) (7) (8) (9) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. Information to be given only where necessary. Indicate the type of examination and the date. For the purpose of Norwegian institutions. Indicate the type and nature of the injuries and the part of the body injured: fracture of arm, bruising of head, fingers, internal injuries, asphyxia, etc. Indicate the certain or probable consequences of the injuries verified: death, permanent or temporary incapacity, total or partial; in the case of temporary incapacity, indicate the probable duration. If the injured person receives treatment in hospital, please give name of hospital. Form E 116 is not required for claims for maternity benefits payable by Belgium. c EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 2 E 117 (1) GRANTING OF CASH BENEFITS IN THE CASE OF MATERNITY AND INCAPACITY FOR WORK Reg. 1408/71:Art. 19. 1. b; Art. 22. 1. a. ii; Art. 22. b; Art. 25. 1. b; Art. 34. b; Art. 52. b; Art. 55. 1. a. ii Reg. 574/72: Art. 18. 6 and8; Art. 24; Art. 26. 7; Art. 61. 6 and8; Art. 64 The competent institution should complete this form and send it to the institution in the place of residence or stay. The competent institution should also inform the workerif cash benefitsare paid by the institutionin the placeof residence(Regulation574/72:Article 61. 8). 1 Institution of the place of residence or stay 1. 1 1. 2 Name Address (2):. 2 3 3. 1 Reference: your E 115 form of. (date) n Employed person n Self-employed person n Unemployed person Surname (2a). 3. 2 Forenames Previous names (2a) Date of birth. 3. 3 Address in the country of residence or stay (2). 3. 4 Identification No (2b):. 4 n is provisionally entitled to receive cash benefits to. from 4. 1 n is not entitled to cash benefits Reason: see the E 118 form attached 4. 2 n is no longer entitled to cash benefits from Reason: see the E 118 form attached. , with possibility of extension. (date) These benefits will be provided (3a) 5 5. 1 n by us 5. 2 n by you on our behalf (3b) 5. 3 n by the employer (4) from. to. (5) 6 (3) (6) 6. 1 6. 2 The allowance should be paid for every day of the week, except n Thursday n Monday n Friday n Tuesday n Saturday n Wednesday n Sunday 6. 3 The daily net amount of this allowance is. (7) if the insured person is not in hospital. (7) if the insured person is in hospital 6. 4 n (8) If the allowance is paid monthly, the amount provided is for 30 days, regardless of the number of days in the month Please inform us as soon as possible of the result of 7 7. 1 n examination (9) 7. 2 n administrative checks 7. 3 n a further medical examination, to be carried out about. (date). a E 117 8 Competent institution 8. 1 8. 2 Name Address (2):. Code number (10):. 8. 3 Stamp 8. 4 8. 5 Date. Signature. Please complete this form in block letters, writing on the dotted lines only. INSTRUCTIONS NOTES * (1) (2) (2a) (2b) (3) (3a) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom, IS = Iceland; FL = Liechtenstein; N = Norway. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. Need not be completed for unemployed persons for whom a form E 119 has been issued. The competent institution may indicate here the method of payment. (3b) When this form is addressed to a French or an Italian institution, this box need not be ticked. (4) To be completed, where appropriate, by Danish, German or Luxembourg institutions. (5) To be completed by German, Spanish and Luxembourg institutions. (6) Complete only in the case indicated at point 5. 2. (7) Indicate the amount in the currency of the competent country. (8) Put a cross in this square if appropriate. (9) Indicate the type of medical examination requested (radiography, analysis of. , etc. ). (10) To be completed where this exists. b EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ overleaf E 118 (1) NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK Reg. 1408/71: Art. 19. 1. b; Art. 22. 1. a. ii, b. iiand c. ii; Art. 22. b; Art. 25. 1. b; Art. 34. b; Art. 52. b; Art. 55. 1. a. ii, b. ii and c. ii Reg. 574/72: Art. 18. 4 and 6; Art. 24; Art. 26. 5 and7; Art. 61. 4 and6; Art. 64 If this form relates to an insured person in active employment, the institution in the place of residence or stay (or the competent institution) should draw up two copies of the form, one of which should be sent to the insured person himself and the other to the sickness and maternity insurance institution or to the institution for insurance against accidents at work and occupational diseases of the competent country (in the place of residence or stay). If it relates to an unemployed person, it is necessary to draw up, in addition to the copies mentioned (one of which is addressed to the unemployed person himself), two extra copies, one of which should be sent to the institution competent in unemployment insurance and the other to the institution of the country to whichthe unemployed personhas goneto seek employment. 1 n Employed person n Self-employed person n Unemployed person 1. 1 Surname (1a). 1. 2 Forenames Previous names (1a) Date of birth. 1. 3 Address in the country of residence or stay (2). 1. 4 Identification No (2a). 2 n Competent institution n Institution in the place of residence or stay 2. 1 2. 2 Name Address (2):. 3 3. 1 3. 2 n The facts which have been brought to our notice n The examination carried out by our doctor on shows n that your incapacity for work is only partial n that you are entitled to partial cash benefits amounting to from (date). (date). (3) 3. 3 n that you are fit for work n that your incapacity for work ended on 3. 4 3. 5 n the last day for which you will receive cash benefits is 3. 6 n the competent institution shall determine the last day for which you receive cash benefits 3. 7 n You are not entitled to benefits because. (4). 4 n Institution in the place of residence or stay n Competent institution 4. 1 4. 2 Name Address (2). Code number (5):. 4. 3 Stamp 4. 4. 4. 5. Date Signature. a E 118 INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of two pages, including the Annex, none of which may be left out even if it does not contain any relevant information. Information for the employed person, the self-employed person or the unemployed person. If you disagree with the decision which is notified to you by this document, you may appeal against it. For details of the legal remedies and periods allowedfor appeals,please seethe Annex. For procedures and time limits you shouldfollow the instructions indicatedfor the competent State. NOTES * (1) (1a) (2) (2a) (3) (4) (5) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. Street, number, post code, town, For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. This information is to be provided only if the competent institution is completing the form. Indicate whether benefits are provided daily, weekly or monthly. Indicate the last day of incapacity for work. To be completed where this exists. b LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS Reg. 574/72: Art. 18. 4; Art. 61. 4 E 118 Annex 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 of 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, within four weeks of the date on which you received notification of the decision lodge an appeal with ‘Den Sociale Ankestyrelse Dagpengeudvalget’, Amaliegade 25, PO. Box 3061, 1021 Copenhagen K (The Social Appeals Board, Daily Cash Benefits Committee). 3. Germany This official act becomes binding if within three months of notification you have not submitted an appeal. Appeals should be lodged in writing within three months with the following German institution: Name Address. 4. Greece If you do not agree with the attached decision you may submit an appeal, within a period of 30 days of the date on which you received the attached decision to: Name Address. 5. Spain You may, within a period of 30 working days of the date on which you received notification of the attached decision, submit an appeal against the decision to the following institution: Name Address. either directly or via the institution of your place of stay or residence. 6. France If you wish to contest the decision attached, you may, within a period of two months of the date on which you received notification of the decision, lodge an appeal with the chief physician of the sickness insurance fund indicated in the box below Name Address. c E 118 Annex 7. Ireland If you do not agree with the decision attached, you may submit a request to the Social Welfare Appeals Office, D'Olier House, D'Olier Street, Dublin 2. Such a request should be made within 21 days of the date on which you received this decision. 8. Italy Decisions of INPS (Sickness and Maternity). An insured person may contest a decision of the INPS by lodging an administrative appeal with the competent Provincial Commission within 90 days of receiving notice of the relevant decision. Moreover, the person concerned may initiate legal proceedings within a period of one year of the date on which the Commission's decision was notified or after 90 days have elapsed since lodging his appeal if the Commission has taken no decision. Decisions of INAIL (accidents at work and occupational diseases) An insured person wishing to contest a decision of INAIL may, within 60 days of the receipt of the notification sent to him, inform INAIL, by registered letter with advice of delivery or notice of receipt, of the reasons why he considers that the decision is 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 of 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 INAIL to court over the matter. The letter setting out the reasons why the insured person does not agree with a decision of INAIL may be sent to INAIL either directly or through the institution of the place of residence or stay. 9. Luxembourg If you do not agree with the decision attached, you have the right to lodge an appeal in principle with the ‘Conseil arbitral des assurances sociales’, within a period of 40 days of the date on which you received notification of the decision. 10. Netherlands If you do not agree with the communication attached, you may request the competent Netherlands institution mentioned in box 2 or 4 of the E 118 form to take an appealable decision within a reasonable period of time. The method of appealing and the time limit within which to appeal will be specified in the decision. 11. Austria If you do not agree with the attached information (form E 118), you can request a decision from the competent Austrian Institution mentioned in box 2 or 4 of the form referred to before, from which you can take the instruction about the admissable legal remedy. 12. Portugal If you do not agree with this decision, you may, — If incapacity for work has not been recognised, lodge an appeal with the Regional Administrative Health Board (Commissão Instaladora da Administraçao Regional de Saude) within eight days of receiving notice of the decision, or — if a claim of cash benefits has been rejected on administrative grounds, lodge an appeal with the locally competent Adminstrative Tribunal (Tribunal Administrative de Circulo) within two months of receiving notice of the decision. If you have been residing outside of Portugal, four months, of receiving notice of the decision. 13. Finland If you wish to contest the decision attached, you may submit an appeal within 30 days of the date on which you received notification of the attached decision to either the Finnish insurance institution indicated in box 2 or 4 of the E 118 form, or the insurance institution nearest to your place of residence, which is also indicated in one of the abovementioned boxes. d E 118 Annex 14. Sweden You may within a period of two months from the actual taking part of the decision lodge an appeal to the competent Swedish institution indicated in boxes 2 or 4 of the E 118 form. In your appeal you should state why you consider that the decision is unjustified. 15. United Kingdom If you do not agree with the decision attached, you may, within 28 days of the date of receipt of the decision, lodge an appeal with the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle-Upon-Tyne, or the Northern Ireland Social Security Agency, Overseas Branch, Belfast, as appropriate. 16. Iceland If you wish to contest the decision attached, you may lodge an appeal with the State Social Security Board, Reykjavik. 17. Liechtenstein (a) concerning sickness insurance: if you do not agree with a decision of a sickness insurance fund, you might ask for a formal decree that must contain the reasons and the information concerning the course of law. Within 60 days after having received this formal decree the persons concerned can file a legal suit with the respective court. (b) concerning accident insurance: if you do not agree with a decree of an accident insurer, you can within two months after having received this decree ask the respective accident insurer to reconsider its decree. If you do not agree with a decree of an accident insurer, you can also, within two months after having received this decree file a legal suit with the respective court. This also applies to the decision of the accident insurers concerning the abovementioned application for reconsideration. 18. Norway An appeal against a Norwegian decision must be sent to the institution indicated in box 2 or 4 in form E 118 within six weeks after receiving notice of the decision. e EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 3 E 125 (1) 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 becompleted for eachrecipient. 1 2 Invoice No. (2) n 1st half year n 2nd half year of the financial year 20. Competent institution to which the form is addressed 2. 1 2. 2 Name Address (3):. Code number (2a). n Employed person n Self-employed person 3 n Pensioner (scheme for employed) n Pensioner (scheme for self-employed) n Student n Other insured person 3. 1 Surname (4). 3. 2 Forenames Previous names (4) Date of birth. 3. 3 Address (3). 3. 4 Address (3) in the competent country. 3. 5 Identification No (4a). 4 Member of the family (5) 4. 1 Surname (4). 4. 2 Forenames Previous names Date of birth. 5 The person mentioned n in box 3 n in box 4 has received benefits under the following Article of Regulation 1408/71: 5. 1 n 19. 1 and 2 n 2. 1. a and 3 n 25. 1, 3 and 4 n 26 n 55. 1 (5b) n 52 (5b) on the basis of the following forms which were sent to us n 2. 1. b and 3 n 29. 1 (5a) n 2. 1. c and 3 n 31 n 22a n 34a n 22b n 34b 5. 2 n an E. form of. n an E 117 form of. 5. 3 valid from The person mentioned to n in box 3 underwent the medical examination requested on. n in box 4. a 6 Expenditure incurred E 125 6. 1 Amount (6) 6. 2 6. 3 6. 4 6. 5 6. 6 For benefits in kind provided from. to. Medical treatment Dental treatment Medicaments Hospitalisation. from. from. to to. 6. 7 Other benefits (7). Total benefits in kind Medical examinations (8). For cash benefits provided Total expenditure from. to. 6. 8 6. 9 6. 10 6. 11 7 Creditor institution 7. 1 7. 2 Name Address (3). Code number (9). 7. 3 Stamp 7. 4 7. 5 Date Signature. 8 Reserved for the institution in the competent country b INSTRUCTIONS E 125 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) (2) (2a) (3) (4) (4a) (5) (5a) (5b) EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of the Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Nederlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. To be indicated if the creditor institution needs this information. To be completed if it is known. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. In the case of Spanish nationals who are pension recipients or claimants, state the number appearing on the national identity card (D. N. I. ), if it exists, even if the identity card is out of date. For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. Complete only when the account refers to a member of the family of the insured person. Applies only in relation to France, for benefits provided up to 31 December 2001. For the purpose of Danish institutions please state if possible the name and address of the employer when benefits are received under Article 52 or 55 (1). Name of employer:. Address:. (6) (7) (8) (9) Indicate the amount in national currency. Indicate the kind of benefits: confinement, dentures, orthopaedic prostheses, spa treatment, ambulance, additional diagnostic means, etc. Indicate the kind of medical checks and examinations carried out. To be completed where this exists. c EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ on page 3 E 126 (1) RATES FOR REFUND OF BENEFITS IN KIND Reg. 1408/71:Art. 22. 1. a. i; Art. 22. 3; Art. 22. a; Art. 22. b; Art. 31. a; Art. 34. a; Art. 34. b; 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 in the place of stay, after completing part B of the form, shouldreturn one copyto the competent institution. A. Request 1 Institution to which the form is addressed (2) 1. 1 1. 2 Name Address (3):. n Employed person n Pensioner (scheme for employed persons) n Student 2 n Self-employed person n Pensioner (scheme for self-employed persons) n Other insured person 2. 1 Surname (3a). 2. 2 Forenames Previous names (3a) Date of birth. 2. 3 n This person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation No 574/72 2. 4 Identification No. 3 Member(s) of the family who received treatment 3. 1 Surname (3a) Forenames Previous names Date of birth 3. 2. 3. 3. 3. 4. a The abovementioned person during a stay in. (country) at. (town) E 126 himself paid for the benefits which he required The person concerned is n a widower/widow and earns an income of n an invalid (4). (4) 4 4. 1 4. 2 4. 3 4. 4 4. 5 5 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. Only in the case of Luxembourg, indicate the amount he/she has to contribute to the cost of treatment. 6 Attached. receipts 7 Competent institution 7. 1 7. 2 Name Address (3). Code number (4a). 7. 3 Stamp 7. 4 7. 5 Date Signature. B. Reply 8 9 Attached. receipts indicating the requested rates n Amount to be reimbursed (5). n No reimbursement 10 Remarks. 11 Institution of the place of stay 11. 1 11. 2 Name Address (3). 11. 3 Stamp 11. 4 11. 5 Date Signature. b INSTRUCTIONS E 126 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 EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway. Symbol of the country to which the institution completing part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. If the institution which would have to provide the benefits in kind is not known, the form may be sent to the liaison body in the country of stay, i. e. : — in Belgium, the ‘Institut nationald'assurancemaladie-invalidité(INAMI)’ (NationalSickness and InvalidityInsurance Institute), Brussels; — in Denmark, the‘Sundhedsministeriet’(Ministry of Health), Copenhagen; — in Germany, the ‘AOK-Bundesverband’(NationalFederationof Local Sickness Funds), Bonn; — in Greece, the regionalor localbranchof the Social InsuranceInstitute (IKA); for mariners, the Seamen's PensionFund (NAT); — in Spain, the‘Instituto Nacionalde la Seguridad Social’(NationalSocialSecurity Institute), Madrid; — in France, the ‘Centrede sécurité socialedes travailleurs migrants’(Centrefor theSocial Security of MigrantWorkers), Paris; — in Ireland, the Department of Health,Dublin; — in Italy, the ‘Ministerodella Sanità’(Ministry of Health),Rome; — in Luxembourg, the ‘L'Union des CaissesdeMaladie’, Luxembourg; — in the Netherlands, the ‘ANOZ Verzekeringen’,Utrecht; — in Austria, the ‘Hauptverband der Österreichische Socialversicherungsträger’ (Main Association of Austrian Social Insurance Institutions), Vienna; — in Portugal, the ‘Departamento de Relações Internacionais e Convenções de Segurança Social’ (Department of International Relations and Social Security Conventions), Lisbon; — in Finland, the ‘Kansaneläkelaitos’ (SocialInsuranceInstitution), Helsinki; — in Sweden, the ‘Riksförsäkringsverket’ (NationalSocialInsuranceBoard), Stockholm; — in Iceland, the ‘Tryggingastofnun rikisins’(State SocialSecurity Institute), Reykjavik; — in Liechtenstein, the ‘Amt für Volkswirtschaft’ (Office of NationalEconomy), Vaduz; — in Norway, the ‘Rikstrygdeverket’ (NationalInsuranceAdministration), Oslo. Street, number, post code, town, country. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. Complete only if the request is sent to a Belgian institution. To be completed where this exists. Indicate the total amount. * (1) (2) (3) (3a) (4) (4a) (5) c EUROPEAN COMMUNITIES Social Security Regulations EEA* See ‘Instructions’ overleaf E 127 (1) INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS Reg. 1408/71:Art. 36. 1and 2 Reg. 574/72:Art. 94; Art. 95 1 Record No. of year 20. (2) 2 Competent institution 2. 1 2. 2 Name Address (3). Code number (3a). 3 The right to benefits in kind has been acquired for the n employed person n self-employed person n pensioner (scheme for employed persons) n pensioner (scheme for self-employed persons) 3. 1 Surname (4). 3. 2 Forenames Previous names (4) Date of birth. 3. 3 Identification number allocated by the competent institution (4b). 4 This individual record concerns: 4. 1 n the family of the worker named in box 3 living at the following address (3):. 4. 2 n the pensioner named in box 3 living at the following address (3):. 4. 3 n the following member of the family of the pensioner named in box 3 4. 3. 1 Surname (4):. 4. 3. 2 Fornames: Previous names (4): Date of birth:. 4. 3. 3 Address (3):. 4. 3. 4 Identification number allocated by the competent institution (4a):. 5 6 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. form of. (date) For the period during which this existed (from. to. ), 6. 1 the number of monthly lump-sum payments n per family or per pensioner and family is. n per family member n per individual a E 127 7 Creditor institution 7. 1 7. 2 Name Address (3). Code number (5). 7. 3 Stamp 7. 4 7. 5 Date. Signature. 8 To be completed by the competent institution Please complete three copies of this form in block letters, writing on the dotted lines only. INSTRUCTIONS The institution in the place of residence should draw up the form for one calendar year and send it to the competent institution through the body designated for the implementationof Article 102. 2 of Regulation 574/72. NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this agreement the present form shall also apply to Iceland, Liechtenstein and Norway. (1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway. (2) The year to be indicated here is that in which the benefits were provided. (3) Street, number, post code, town, country. (3a) To be completed if it is known. (4) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4b) For Italian nationals indicate, if possible, the insurance number and/or the ‘codice fiscale’. (5) To be completed where this exists. b