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Документ 02002D0154-20060401

Консолидиран текст: 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)

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ELI: http://data.europa.eu/eli/dec/2002/154(1)/2006-04-01

2002D0154 — EN — 01.04.2006 — 003.001

This document is meant purely as a documentation tool and the institutions do not assume any liability for its contents

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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)

(OJ L 054, 25.2.2002, p.1)

Amended by:

 

 

Official Journal

  No

page

date

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DECISION No 187 of 27 June 2002

  L 93

40

10.4.2003

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DECISION No 198 of 23 March 2004

  L 259

1

5.8.2004

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DECISION No 202 of 17 March 2005

  L 77

1

15.3.2006



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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 is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 ( 2 ) 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 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;

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

Sebastião PINTO PIZARRO

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ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 115(1)CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORKRegulation (EEC) No 1408/71: Article (19)(1)(b); Article 22(1)(a)(ii); Article 25(1)(b); Article 52(b) and Article 55(1)(a)(ii)Regulation (EEC) No 574/72: Article 18(2) and (3); Article 24; Article 26(5) and (7); Article 61(2) and (3) and Article 64If the form is drawn up for an insured person in active employment, one copy only should be completed and sent to the institution competent asregards sickness and maternity insurance or as regards an insurance against accidents at work and occupational diseases. However, if it concernsan unemployed person, two additional copies should be drawn up, one of which should be sent to the institution competent in unemploymentinsurance, the other to the corresponding institution in the country to which the unemployed person has gone to seek employment.Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.1.Competent institution1.1Name: …………………………………………………………………………………………………………………………………………………1.2Address: ………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………….1.3Identification number of the institution:…………………………………………………………………………………………………………………2.Employed personSelf-employed personUnemployed person2.1Surname(s) (2):Surname(s) at birth (if different):…………………………………………………………………………………………………………………………………………………………2.2Forenames:Date of birth:…………………………………………………………………………………………………………………………………………………….….2.3Personal identification number:…………………………………………………………………………………………………………………………………………………………...2.4Holds an E 119 form issued on ……………………………………………………………………………………………… (3)and an E 303 form issued on ………………………………………………………………………………………………… (3)3.Employer (4)3.1Name of employer or firm: ………………….……………………………………………………………………………………………………….3.2Address: ….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….A. (5) Claim for benefits4.The person mentioned in box 2 applied on ………………………………………………………………………………………………. (date)for cash benefits forin-patient treatment from ………………… to ……………………(dates) in a hospital or in a prevention or rehabilitation centre (6)incapacity for workdue to4.1sicknessmaternity (expected date of confinement: ……………………………………………………..)accident at workaccident sustained on ……………………………………………………………………….(date)occupational diseaseadoptionreduced compensation in case of maternity and adoption

5.The certificate of the doctor treating him/heris attachedcould not be supplied6.In the opinion of our examining doctorwhose report is attachedwhose report will be sent to you as soon as possible6.1the incapacity for work began on ………………………………………………………………………………………………………………and will probably continue until …………………………..…………………………………………………………………………………….6.2there is no incapacity for work (7)7.The person concerned is deemed not to have complied with the provisions of our legislation for the following reasons:…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………..8.The incapacity for work was presumably caused by an accident for which a third party was responsible.8.1.The incapacity for work was due to other specific circumstances as set out in the attached documentation.8.2A report on this accident with the address of the third party involved is attached to this form.8.3Other documentation on the cause of the incapacity for work is attached to this form.9.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.We are not willing to provide cash benefits to the person concerned on your behalf.B. (5) Extension of the incapacity for work11.With reference to11.1our E 115 form of …………………………………………………………….(date)11.2your E 117 form of ……………………………………………………………(date)11.3we wish to inform you that, in the opinion of our examining doctorwhose report is attachedwhose report will be sent to you as soon as possiblethe person mentioned in box 2 will probably remain incapable of work until …………………………………………………..… inclusive.12.Institution of the place of residence or stay12.1Name: ……………………………………………………………………………………………………………………………………………….12.2Identification number of the institution: .….………………………………………………………………………………………………………12.3Address: ………….…………………………………………………………………………………………………………………………………..…………………………………………………….…………………………………………………………………………………………………....12.4Stamp12.5Date: .……………………………………………………12.6Signature:…………………………………………………………….

Instructions for the persons concernedIn 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 gliinfortuni sul lavoro (INAIL).For the Netherlands, if the competent sickness insurance institution is not known, send the form to the UWV, Postbus 57002, 1040 CC Amsterdam.In Slovenia you should submit this form, in case of maternity cash benefits to the competentCenter za socialno delo Ljubljana Bežigrad, Centralnaenota za starševsko varstvo in družinske prejemke (Centre for Social Work Ljubljana Bežigrad, Central Unit for Parental Protection and Family Benefits) and in case of incapacity for work to the competent regional unit of theZavod za zdravstveno zavarovanje Slovenije (ZZZS)(HealthInsurance Institute of Slovenia).NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Give the full surname in the order of civil status.(3) Complete only if the form concerns an unemployed person.(4) For unemployed persons, indicate the last employer.(5) Complete either part A or part B and put a cross in the square corresponding to the part completed.(6) Concerning persons insured at a German health insurance fund or at an Austrian or Belgian Institution: if the social insurance institution of the place of residence does not know the exact date of leaving the hospital when issuing this form, it is to complete this information as soonas possible at a later date.(7) Please attach a copy of an E 118 form sent to the person concerned.(8) If the form is being sent to a German, an Italian, a Hungarian or a Polish institution, this box need not be ticked.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 116(1)MEDICAL REPORT RELATING TO INCAPACITY FOR WORK(SICKNESS, MATERNITY, ACCIDENT AT WORK, OCCUPATIONAL DISEASE)Regulation (EEC) No 1408/71: Article (19)(1)(b); Article 22(1)(a)(ii); (1)(b)(ii); (1)(c)(ii); Article 25(1)(b); Article 52(b); Article 55(1)(a)(ii); (1)(b)(ii)and (1)(c)(ii)Regulation (EEC) No 574/72: Article 18(2) and (3); Article 24; Article 26(5) and (7); Article 61(2) and (3); Article 64; Article 65(2) and (4)To be completed by the doctor of the institution which draws up an E 115 form to be attached to that form and sent under sealed cover in thecase of sickness or maternity (2).Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.1.Competent institution to which the form is addressed1.1Name: …………………………………………………………………………………………………………………………………………………..1.2Identification number of the institution: …………………………………………………………………………………………………………….…1.3Address: ………….…………………………………………………………………………………………………………………………………..…..………………………………………………………………………………………………………………………………………………………………1.4Reference: our E 116 form of …………………………………………………………………………………………………………………. (date)2.Attached to an E 115 form of ………………………………………………………………………………………………………………….. (date)3.The person concerned3.1Surname(s) (3):…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………3.2Surname(s) at birth (if different):…………………………………………………………………………………………………………………………………………………………..3.3Forenames:Date of birth…………………………………………………………………………………………………………………………………………………….……3.4Address in the country of residence or stay: ………………………………………………………………………………………………….…….………………………………………………………………………………………………………………………………………………………….…..3.5Personal identification number:………………………………..………………………………………………………………………………………………………………….…….…..4.I, the undersigned, ……………………………………………………………………………………………………………. doctor of medicine,having examined the person mentioned aboveon …………………………………………………………………………………………………………………………………………………………4.1consider that it iscase of sicknesscase of maternity (expected date of confinement ……………………………………………….)4.2that it is probablyan accident at workan occupational diseasean accident4.3a relapse or aggravation

E 116A. General report5.To be completed in every case5.1Medical history and present symptoms: ……………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5.2Clinical examination: …………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5.3Other observations: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5.4Special examinations (4): ………………………………………………………………………………………………………………………….….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5.5Diagnosis: ……………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5.6Conclusions: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...5.7The person concerned has not been found to be unfit for work5.8The person concerned has been found to be unfit for workfrom ……………………………………………………………. to ….…………………………………………………………………………..5.9The person concerned has been found partly unfit for work to a degree of(………………… %) from …………………………………... to …………………………………………………………………………. (5)5.10The person concerned will be given a further medical examination on ……………………………………………………………………….5.11The person concerned should be fit for work on …………………….…………………………………………………………………………..B. Reports in the case of an accident at work6.First medical report6.1This accident has resulted in the following injuries (6): ……………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………6.2These injurieshave hadwill have the following effects (7)………………………………………………………………………………………………………………………………………………….…..……….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………6.3Incapacity for work began on ………………………………………………………………………………………………………………………….6.4The injured person is being treatedat homeat the doctor's surgeryin hospitalelsewhereAddress (8) : …………….……………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………….

E 1167.Latest medical report7.1Treatment ended on: ………………………………………………………………………………………………………………………………7.2Injuries stabilised on:…………………………………………………………………………………………………………..7.3with complete recovery7.4and will probably have the following consequences:……………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..7.5Detailed description of the victim's condition after recovery or at the end of medical treatment:……………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..8.Institution in the place of residence or stay:8.1Name: …………………………………………………………………………………………………………….……………………………8.2Number of the competent institution:……………………………………………………………………………………………………………………8.3Address: …………………………………………………………………………………………………………….……………………………….……………………………………………………………………………………………………………………………….……………………………..8.4Stamp8.5Date: …………………………………………………………8.6Signature:………………………………………….………………………NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland Indicate the type of examination and the date.(2) Form E 116 is not required for claims for maternity benefits payable by Belgium. For Belgium, this form should always be sent first to theBelgian institution competent as regards sickness insurance. In the Czech Republic, Liechtenstein, Finland, Norway and Sweden the formis filled in by the doctor the person concerned is visiting and verified by the insurance institution.(3) Give the full surname in the order of civil status.(4) Indicate the type of examination and the date.(5) For the purpose of Norwegian institutions.(6) 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.(7) Indicate the certain or probable consequences of the injuries verified: death, permanent or temporary incapacity, total or partial; in thecase of temporary incapacity, indicate the probable duration.(8) If the injured person receives treatment in hospital, please give name of hospital.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 117(1)GRANTING OF CASH BENEFITS IN THE CASE OF MATERNITY AND INCAPACITY FOR WORKRegulation (EEC) No 1408/71: Article(19)(1)(b); Article 22(1)(a)(ii); Article 25(1)(b); Article 52(b) and Article 55(1)(a)(ii)Regulation (EEC) No 574/72: Article 18(6) and (8); Article 24; Article 26(7); Article 61(6) and (8) and Article 64The competent institution should complete this form and send it to the institution in the place of residence or stay. The competent institution shouldalso inform the worker if cash benefits are paid by the institution in the place of residence.Please complete this form in block letters, writing on the dotted lines only. The form consists of two pages.1. Institution of the place of residence or stay1.1 Name: ………………………………………………………………………………………………………………………………………………….1.2 Identification number of the institution: ……………………………………………..………………………………………………………………1.3 Address: ………….………………………………………………………..………………………………………………………………………...….………………………………………………………………………………………………………………………………………………………….…2. Reference: your E 115 form of …… .……………………………………………………………………………………………………….. (date)3.Employed personSelf-employed personUnemployed person3.1Surname(s) (2):……………………………………………………………………………Surname(s) at birth (if different):………………………………………………………………………………3.2Forename(s):……………………………………………………………………………Date of birth:……………………………………………………………………………3.3 Address in the country of residence or stay: ……………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………..3.4 Personal identification number:………………………………..………………………………………………………………………………………………………………….………..4. The person referred to in box 34.1is provisionally entitled to receive cash benefitsfrom …………………………………………………….. to …………..………………………………………, with possibility of extension4.2.is not entitled to cash benefitsReason: see the E 118 form attached.4.3.is no longer entitled to cash benefits from ……………………………………………………………………………………………… (date)Reason: see the E 118 form attached.5. These benefits will be provided (3)5.1by us5.2by you on our behalf (4)5.3by the employer (5)from ……………….………………………………………. to ………………………..……………………………………….. (6)6. (7)(8)6.1 The allowance should be paid for every day of the week, exceptMondayTuesdayWednesdayThursdayFridaySaturdaySunday6.2 The daily net amount of this allowance is……………………………………..(9) if the insured person is not in hospital……………………………………..(9) if the insured person is in hospital6.3If the allowance is paid monthly, the amount provided is for 30 days, regardless of the number of days in the month

E 1177. Please inform us as soon as possible of the result of7.1examination (10): ………………………………………………………………………………………………………………………………….7.2administrative checks:……………………………………………………………………………………………………………………………….7.3a further medical examination, to be carried out about ………..………………………………………………………………………. (date)8. Competent institution8.1 Name: ………………………………………………………………………………………………………………………………………………….8.2 Identification number of the institution: ….….………………………………………………………………………………………………………8.3 Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...8.4 Stamp8.5 Date: .………………………………………………………8.6. Signature……………………………………………………………….NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Give the full name in the order of civil status.(3) Need not be completed for unemployed persons for whom a form E 119 has been issued.(4) The competent institution may indicate here the method of payment.(5) When this form is addressed to a French, a Polish, an Italian or a Hungarian institution, this box need not be ticked.(6) To be completed by Danish, German, Luxembourg, Polish, Hungarian or Slovak institutions.(7) To be completed by German, Luxembourg, Polish, Slovak and Spanish institutions.(8) Complete only in the case indicated at point 5.2.(9) Indicate the amount in national currency.(10) Indicate the type of medical examination requested (radiography, analysis of…, etc.).

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 118(1)NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORKRegulation (EEC) No 1408/71: Article 19(1)(b); Article 22(1)(a)(ii), (b)(ii) and (c)(ii); Article 25(1)(b); Article 52(b); Article 55(1)(a)(ii), (b)(ii) and (c)(ii)Regulation (EEC) No 574/72: Article 18(4) and (6); Article 24; Article 26(5) and (7); Article 61(4) and (6) and Article 64If this form relates to an insured person in active employment, the institution in the place of residence or stay (or the competent institution) shoulddraw 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 insuranceinstitution or to the institution for insurance against accidents at work and occupational diseases of the competent country (in the place of residenceor stay). If it relates to an unemployed person, it is necessary to draw up, in addition to thecopies mentioned (one of which is addressed to theunemployed person himself), two extra copies, one of which should be sent to the institution competent in unemployment insurance and the otherto the institution of the country to which the unemployed person has gone to seek employment.Please complete this form in block letters, writing on the dotted lines only. It consists of two pages and of a three-page Annex.1.The beneficiary1.1Surname(s):Surname(s) at birth (if different):………………………………………………………………………………………………………………………………………………………….1.2Forename(s):Date of birth:…………………………………………………………………………………………………………………………………………………………1.3Address in the country of residence or stay: ……………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………..1.4Personal identification number:………………………………..………………………………………………………………………………………………………………….………..2.Competent institutionInstitution in the place of residence or stay2.1Name: ………………………………………………………………………………………………………………………………………………….2.2Identification number of the institution: ……………………………………………..………………………………………………………………2.3Address: ………….………………………………………………………..………………………………………………………………………...….………………………………………………………………………………………………………………………………………………………….…3.The facts which have been brought to our noticeThe examination carried out by our doctor on …………………………………………………………………………………………. (date)shows3.1that your incapacity for work is only partial3.2that you are entitled to partial cash benefits amounting to ……………………………………………………………………………..(2)from …………………………………………………………………………………………………………………………………..… (date)3.3that you are fit for work3.4that your incapacity for work ended on ………………………………………………………………………………………………..… (3)3.5The last day for which you will receive cash benefits is ……………………………………………………………………………………….3.6The competent institution shall determine the last day for which you receive cash benefits3.7You are not entitled to benefits because …………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………….4.Institution in the place of residence or stayCompetent institution4.1Name: ………………………………………………………………………………………………………………………………………………….4.2Identification code of the institution: ….….………………………………………………………………………………………………………4.3Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...4.4Stamp4.5Date: .………………………………………………………4.6Signature:………………………………………………………….

E 118Information 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 allowed for appeals, please see the Annex. For procedures and time limits you should follow the instructions indicated for the competent State.NOTES(1) Symbol of the country to which the institution completing the form belongs: AT = Austria; BE = Belgium; CY = Cyprus; CZ = Czech Republic;DE=Germany; DK=Denmark; EE = Estonia; ES = Spain; FI = Finland; FR = France; UK = United Kingdom; GR = Greece; HU = Hungary;IE = Ireland; IT = Italy; LT = Lithuania; LU = Luxembourg; LV = Latvia; MT = Malta; NL = Netherlands; PL = Poland; PT=Portugal;SE = Sweden; SI = Slovenia; SK = Slovakia; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.(2) This information is to be provided only if the competent institution is completing the form. Indicate whether benefits are provided daily,weekly or monthly.(3) Indicate the last day of incapacity for work.

E 118 AnnexLEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALSRegulation (EEC) No 574/72: Article 18(4) and Article 61(4)1. BelgiumIf 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 byregistered letter to the office of the clerk of the competent labour court within a period of three months of the date on which you received notificationof 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. Czech RepublicIf you do not agree with the notification attached, you have the right to lodge an appeal to the competent Czech institution indicated in point 2 or4 of the form within three days after the delivery of the notification. The method of, and the closing date for, appeal are stated in the decision.3.DenmarkIf you wish to contest the decision attached, you may, within four weeks of the date on which you received notification of the decision, lodge anappeal with Den Sociale Ankestyrelse Dagpengeudvalget, Amaliegade 25, PO. Box 3061, 1021 Copenhagen K (The Social Appeals Board, DailyCash Benefits Committee).4. GermanyThis official act becomes binding if within three months of notification you have not submitted an appeal. Appeals should be lodged in writing withinthree months with the following German institution:Name: ……………………………………………………………………………………………………………………………….….........…..Address:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….….5. EstoniaIf you wish to contest the decision attached you may submit an appeal, within a period of 30 days to Eesti Haigekassa, Lembitu 10, Tallinn10114.6. GreeceIf 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 attacheddecision to:Name: ……………………………………………………………………………………………………………………………….……......…..Address:………………………………………………………………………………………………………………………………….……..…………………………………………………………………………………………………………………………………………………..………7. SpainYou 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 decisionto the following institution:Name: ……………………………………………………………………………………………………………………………….…...……….Address:………………………………………………………………………………………………………………………………….………..………………………………………………………………………………………………………………………………………………..………8. FranceIf 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:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……...9. IrelandIf 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, Dublin2. Such a request should be made within 21 days of the date on which you received this decision.

E 118 Annex10. ItalyDecisions 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 within90 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 wasnotified 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,byregistered letter with advice of delivery or notice of receipt, of the reasons why he considers that the decision is unjustified; in the case ofpermanent incapacity for work, he should indicate the amount of the allowance to which he feels entitled; in all cases, a medical certificate insupport 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 toabove, 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 throughthe institution of the place of residence or stay.11. CyprusIf you are not satisfied by the decision attached you may within fifteen days of the notification of the decision appeal to the Minister of Labourand Social Insurance. If you are not satisfied by the Minister's decision you may appeal to the Supreme Court within 75 days from the day ofthe notification of the Minister's decision.12. LatviaIf you do not agree with the attached decision you may submit an appeal, within a period of one month of the date on which you received theattached decision to:Name: ……………………………………………………………………………………………………………………………….………........Address:……………………………………………………………………………………………………………………………………..….……………………………………………………………………………………………………………………………………………………….….13. LithuaniaIf you wish to contest the decision attached, you may lodge an appeal with the Administrative Disputes Commission within one month of the dateon which you received notification of this decision.14. LuxembourgIf 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.15. HungaryIf you do not agree with the attached communication, you can request a decision from the competent Hungarian institution (box 2 or 4 of the formE 118). The decision of the competent institution is appealable within 15 days of the date on which you received notification of the decision.16. MaltaIf you wish to contest the decision attached, you may lodge an appeal with the Department of Social Security, Valletta within 30 days of the dateof decision.17. NetherlandsIf you do not agree with the communication attached, you may request the competent Netherlands institution mentioned in box 2 or 4 of theE 118 form to take an appealable decision within a reasonable period of time. The method of appealing and the time limit within which to appealwill be specified in the decision.18. AustriaIf you do not agree with the attached information (form E 118), you can request a decision from the competent Austrian Institution mentioned inbox 2 or 4 of the form referred to before, from which you can take the instruction about the admissible legal remedy.19. PolandIf you are not satisfied with the decision enclosed, you have the right to apply for decision to the Zaklad Ubezpieczen Spolecznych — ZUS (SocialInsurance institution) with territorial jurisdiction over the seat of employer, and in the case of farmers, to the regional branch of Kasa RolniczegoUbezpieczenia Spolecznego — KRUS (Agricultural Social Insurance Fund). In this branch you will be issued with the decision on eligibility forbenefit and informed about possible measures of appeal against the decision.20. PortugalIf 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 daAdministraçao 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 Administrative Tribunal(Tribunal Administrative de Circulo) within two months of receiving notice of the decision. If you have been residing outside of Portugal,

E 118 Annex21. SloveniaIf you do not agree with the decision, you may file a suit with the Labour and Social Court in Ljubljana, Komenskega 7, within 30 days of havingbeen served with the decision.22. SlovakiaIf you do not agree with the information stated and unless there was no decision issued in the case so far, you may ask the competent branch ofthe Social Insurance Agency to issue such a decision. You may appeal to the headquarters of the Social Insurance Agency within 15 days after thedelivery of the decision issued by the local branch. The decision of the Social Insurance Agency HQ in the matter of benefits is final; neverthelesswithin two months after its delivery you may file an appeal against it at the competent regional court.In matters other than benefits you may file for correction remedies against the decision of the Social Insurance Agency HQ within 30 days afterits delivery at the competent regional court. The address of the Social Insurance Agency HQ is: Sociálna poist'ovňa, ústredie, ul. 29. augusta č.8–10, 813 63 Bratislava 1.23. FinlandIf 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 attacheddecision 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 ofresidence, which is also indicated in one of the abovementioned boxes.24. SwedenYou may within a period of two months from the actual taking part of the decision lodge an appeal to the competent Swedish institution indicatedin boxes 2 or 4 of the E 118 form. In your appeal you should state why you consider that the decision is unjustified.25. United KingdomIf 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 PensionService, International pension Centre, Tyneview Park Newcastle-upon-Tyne, or the Northern Ireland Social Security Agency, Overseas Branch,Belfast, as appropriate.26. IcelandIf you wish to contest the decision attached, you may lodge an appeal with the State Social Security Board, Reykjavik.27. Liechtenstein(a) Concerning sickness insurance: if you do not agree with a decision of a sickness insurance fund, you might ask for a formal decree thatmust 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 receivedthis 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 legalsuit with the respective court. This also applies to the decision of the accident insurers concerning the abovementioned application forreconsideration.28. NorwayAn 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 noticeof the decision.29. SwitzerlandIf you do not agree with the decision attached, you may lodge an objection with the institution within 30 days of the date of receipt of the decision.The decision on the objection will specify the remedy and the period for lodging an appeal.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 125(1)INDIVIDUAL RECORD OF ACTUAL EXPENDITURERegulation (EEC) No 1408/71: Article 36(1) and (2); Article 63(1); Article 87(1)Regulation (EEC) No 574/72: Article 93(1), (2), (4) and (5); Article 105(1)A separate form should be completed for each recipient of the care.Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.1.Invoice No ...........................First half yearSecond half yearof the financial year 20 ………………2.Competent institution to which the form is addressed2.1Name: ………………………………………………………………………………………………………………………………………………….2.2Identification number of the institution: ……………………………………………………………………………………………………………2.3Address: ………….…………………………………………………………………………………………………………………………………..3.Recipient of the care3.1Surname(s) (2):3.2Surname(s) at birth (if different):………………………………………………...3.3Forename(s):Date of birth :…………………………………………………………..………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………...3.4Personal identification number (3):(a)allocated by the competent institution…………………………………………………………………………………………………………………………………………………………...(b)allocated by the creditor institution3.5The insured person isa employed persona self-employed persona frontier worker (employed)a frontier worker (self employed)an unemployed worker4.The person mentioned above has received benefitson the basis of the following document:4.1European Health Insurance Card number: ………………………………… Expiry date:……………………………………. …….certificate provisionally replacing the European Health Insurance Card number:…………………………………………………………... dated:………………………………………………… Valid from………………………………to…………………………………...……………..E .…… form dated ……………………………………… valid from ……………………………… to ………………………………..4.2The person mentioned aboveunderwent the medical examination requested on ……………………………………………………….………………………………………..

E 1255.Expenditure incurredAmount (4)5.1For benefits in kind providedfrom ……………………..to .………………………..…………………………………………..in consequence of (5)diseasenot professional accidentprofessional accident or disease5.2Medical treatment……………………………………………………………..…………………………………………..5.3Dental treatment……………………………………………………………..…………………………………………..5.4Medicaments……………………………………………………………..…………………………………………..5.5Hospitalisationfrom ……………………..to .………………………..…………………………………………..from ……………………..to .………………………..…………………………………………..5.6Other benefits (6)……………………………………………………………..…………………………………………..……………………………………………………………..…………………………………………..5.7Total benefits in kind5.8Medical examinations (7)……………………………………………………………..……………………………………………………………………………………………………………….………………………………………… ______________________________5.9For cash benefits providedfrom ……………………..to .………………………..………………………………………… ______________________________5.10Total expenditure============================—————————————————————————6.Creditor institution6.1Name: ………………………………………………………………………………………………………………………………………………….6.2Identification number of the institution: ….….………………………………………………………………………………………………………6.3Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...6.4Stamp (8)6.5Date: .………………………………………………………6.6Signature……………………………………………………………….7.Reserved for the institution in the competent country

E 125NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Give the full surname in the order of civil status.(3) If the recipient of care is a member of family registered on the basis of E 106, please indicate the personal identification number of theinsured person.(4) Indicate the amount in national currency.(5) When the form is sent to a Swiss Institution.(6) Indicate the kind of benefits: confinement, dentures, orthopaedic prostheses, spa treatment, ambulance, additional diagnostic means, etc.(7) Indicate the kind of medical checks and examinations carried out.(8) An electronically sent and signed form does not need to be stamped.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 126(1)RATES FOR REFUND OF BENEFITS IN KINDRegulation (EEC) No 1408/71: Article 22(1)(a)(i); Article 22(3); Article 22(a); Article 31(a) and Article 34(a);Regulation (EEC) No 574/72: Article 34The competent institution should complete part A of the form and send, either directly or through the liaison body, two copies to the institution whichwould 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 Bof the form, should return one copy to the competent institution.Please complete this form in block letters, writing on the dotted lines only. It consists of two pages.A. Request1. Institution to which the form is addressed (2)1.1 Name: ………………………………………………………………………………………………………………………………………………...1.2 Identification number of the institution:1.3 Address: ……………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………...2. Entitled person2.1 Surname(s) (3) :2.2 Surname(s) at birth (if different):…………………………………………………………………………………………………………………………………………………….2.3Forename(s):……………………………………………………………………………Date of birth:………………………………………………………..………………..2.4 Personal identification number:…………………………………………………………………………………………………………………………………………………………...2.5The person is/was:an employed persona self-employed persona frontier worker (employed)a frontier worker (self-employed)an unemployed worker3. Family member of the entitled person if he or she received the care:3.1 Surname(s) (3):.............................................................................................................................................................................................3.2 Forename(s): .......................................................................................................Date of birth: ................................................................3.3 Personal identification number: …………………………………………………………………...…………………………………………….4. The above mentioned person4.1 during a stay in ............................................................................................................................................................................ (country)4.2 at ...................................................................................................................................................................................................... (town)4.3 himself paid for the benefits which he required ………………………………………………………………………...………………………….5. Please indicate on the receipts attached, for each benefit separately, the amount to be refunded to the person concerned accordingto the rates administered by the institution of the place of stay. Only in the case of Luxembourg, indicate the amount he/she has tocontribute to the cost of treatment.6. Attached ...................................... receipts.

E 1267. Competent institution7.1 Name: ………………………………………………………………………………………………………………………………………………….7.2 Identification number of the institution: ….….………………………………………………………………………………………………………7.3 Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...7.4 Stamp7.5 Date: .………………………………………………………7.6 Signature:……………………………………………………………….B. Reply8. Attached ........................ receipts indicating the requested rates9.Amount to be reimbursed …………………………………………….No reimbursement10. Remarks : ………………………………………………………………………………………………………………………………………….....…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………..11. Institution of the place of stay11.1 Name: ………………………………………………………………………………………………………………………………………………….11.2 Identification number of the institution: ….….………………………………………………………………………………………………………11.3 Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...11.4 Stamp11.5 Date: .………………………………………………………11.6 Signature:……………………………………………………………….NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia;GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary;MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = UnitedKingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.(2) 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.:inBelgium, the ‘Institut national d'assurance maladie-invalidité’ ‘(INAMI)’ (National Sickness and Invalidity Insurance Institute), Brussels;in theCzech Republic, the ‘CMU’ (Centre for International Reimbursements), Prague;inDenmark, the ‘Indenrings- og Sundhedsministeriet’ (Ministry of the Interior and Health), Copenhagen;inGermany, the ‘DVKA’ (German Liaison Agency Health Insurance — International), Bonn;inEstonia, the ‘Eesti Haigekassa’, (Health Insurance Fund));inGreece, the regional or local branch of the Social Insurance Institute (IKA); for mariners, the Seamen's Pension Fund (NAT);inSpain, the ‘Instituto Nacional de la Seguridad Social’ (National Social Security Institute), Madrid;inFrance, the ‘Centre des Liaisons Européennes et Internationales de Sécurité Sociale’ (Centre of European and International Liaisons forSocial Security), Paris;inIreland, the Department of Health, Dublin;inItaly, the ‘Ministero della Sanità’ (Ministry of Health), Rome;inCyprus, in Cyprus, the ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia;inLatvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency), in Riga;inLithuania, the ‘Valstybinė ligonių kasa’ (State Patient Fund), Vilnius;inLuxembourg, the ‘Union des Caisses de Maladie’, Luxembourg;inHungary, the ‘Országos Egészségbiztositási Pénztár’ (National Health Insurance Fund), Budapest;inMalta, the Entitlement Unit, Ministry of Health, 23, St. John Street, Valletta;in theNetherlands, the ‘Agis Zorgverzekeringen’, Utrecht;inAustria, the ‘Hauptverband der österreichischen Sozialversicherungsträger’ (Main Association of Austrian Social Insurance Institutions), Vienna;inPoland, the Narodowy Fundusz Zdrowia (National Health Fund), Warsaw;inPortugal, the ‘Departamento de Relações Internacionais e Convenções de Segurança Social’ (Department of International Relationsand Social Security Conventions), Lisbon;inSlovenia, the ‘Zavod za zdravstveno zavarovanje Slovenije-Direkcija’ (Health Insurance Institute of Slovenia-Directorate), Ljubljana;inSlovakia, the ‘Úrad pre dohl'ad nad zdravotnou starostlivost'ou’, (Health Care Supervision Authority), Bratislava;

inFinland, the ‘Kansaneläkelaitos’ (Social Insurance Institution), Helsinki;inSweden, the ‘Riksförsäkringsverket’ (National Social Insurance Board), Stockholm;inIceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;inLiechtenstein, the ‘Amt für Volkswirtschaft’ (Office of National Economy), Vaduz;inNorway, the ‘Rikstrygdeverket’ (National Insurance Administration), Oslo;inSwitzerland, the ‘Institution commune LAMal — Gemeinsame Einrichtung KVG — Istituzione commune LAMal’ (Joint Institution underthe Federal Sickness Insurance Act), in Solothurn.(3) Give the full surname in the order of civil status.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 127(1)INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTSRegulation (EEC) No 1408/71: Article 36(1) and (2)Regulation (EEC) No 574/72: Article 94; Article 95The institution in the place of residence should draw up the form for one calendar year and send it to the competent institution through the bodydesignated for the implementation of Article 102(2) of Regulation (EEC) No 574/72.Please complete three copies of this form in block letters, writing on the dotted lines only. A separate form must be completed foreach pensioner and each member of the family of a pensioner.1.Record No: …………………………………………………………………..of year 20 ……………….......................................................................(2)2.Competent institution2.1Name: ………………………………………………………………………………………………………………………………………………….2.2Identification number of the institution: ……………………………………………………………………………………………………………2.3Address: ………….…………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………The right to benefits in kind has been acquired for the3.employedpensionerself-employed person3.1Surname(s) (3):………………………………………………………………………………………………………………...3.2Surname(s) at birth (if different): ………………………………………………………………………………………………………………...3.3Forename(s):Date of birth:…………………………………………………………..…………………………………………………3.4Personal identification number allocated by the competent institution:…………………………………………………………………………………………………………………………………………………………...3.5Personal identification number allocated by the creditor institution:……………………………………………………………………….…………………………………………………………………………………..4.This individual record concerns:4.1the family of the person named in box 3 living at the following address: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………..4.2the pensioner named in box 3 living at the following address: ……………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………….4.3the following member of the family of the pensioner named in box 3the following member of the family of the person named in box 3 (4)4.3.1Surname(s) (3):………………………………………………………………………………………………………………...4.3.2Forename(s):Date of birth:………………………………………..………………………….…………………………………………………………………….4.3.3Address: ……………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………..4.3.4Personal identification number allocated by the competent institution:…………………………………………………………………………………………………………………………………………………..4.3.5Personal identification number allocated by the creditor institution:……………………………………………………………………………………………………………………………………………………

E 1275.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 themembers of his family, as certified by yourE ……………… form of ……………………………………………………………………… (date)6.For the period during which this existed(from ............................................. to ..............................................)6.1the number of monthly lump-sum payments is …………………………………………………………………………………………………….6.2per family irrespective of the number of family members and one tariff rate;per pensioner or his/her family members — for every one the individual E-form and the same tariff rate for the pensioner as well asfor his/her family members;per individual (4).7.Creditor institution7.1Name: ………………………………………………………………………………………………………………………………………………….7.2Identification number of the institution: ….….………………………………………………………………………………………………………7.3Address: ………….……………………………………………………………………………………………………………………………………..…………………………………………………….……………………………………………………………………………………………………...7.4Stamp (8)7.5Date: .………………………………………………………7.6Signature:……………………………………………………………….NOTES(1) Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Give the full surname in order of civil status.(3) The year to be indicated here is that in which the benefits were provided.(4) In case of special lump sum payment scheme.(5) An electronically sent and signed form does not need to be stamped.


( 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.

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