1998D0443 — EN — 01.04.2006 — 002.001

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 168

of 11 June 1998

on the amending of forms E 121 and E 127 and the discontinuance of form E 122

(Text with EEA relevance)

(98/443/EC)

(OJ L 195, 11.7.1998, p.37)

Amended by:

 

 

Official Journal

  No

page

date

 M1

DECISION No 179 of 18 April 2000

  L 54

1

25.2.2002

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DECISION No 202 of 17 March 2005

  L 77

1

15.3.2006



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DECISION No 168

of 11 June 1998

on the amending of forms E 121 and E 127 and the discontinuance of form E 122

(Text with EEA relevance)

(98/443/EC)



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

Having regard to Article 81(a) of Council Regulation 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, 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 of 21 March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the application of the Regulations,

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

Having regard to Decision No 170 of 11 June 1998 amending Decision No 141 of 17 October 1989 amending Decision No 127 of 17 October 1985 concerning the compilation of the lists provided for in Article 94(4) and Article 95(4) of Council Regulation (EEC) No 574/72 of 21 March 1972,

Whereas Council Regulation (EC) No 3095/95 of 22 December 1995 amended Regulation (EEC) No 574/72, firstly Article 17(2) and Article 30(1), by limiting to one year the period of validity of form E 122 issued by German, Italian or Portuguese institutions, and secondly Article 95, by replacing the average cost per family by the average cost per person;

Whereas this amendment to Article 95 of Regulation (EEC) No 574/72 will not, however, take effect until 1 January 2002 in the French Republic;

Whereas Council Regulation (EC) No 1223/98 of 4 June 1998 amended Articles 29 and 31 of Regulation (EEC) No 1408/71 and Articles 29, 30, 31, 93 and 95 of Regulation (EEC) No 574/72;

Whereas forms E 121 and E 127 must therefore be adapted and form E 122 discontinued;

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

Whereas by Decision of the EEA Joint Committee the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 will be adapted and implemented 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 forms should be issued is the subject of Recommendation No 15 of the Administrative Commission,

HAS DECIDED AS FOLLOWS:



1.

The model forms E 121 and E 127 reproduced in Decision No 153 of 7 October 1993 shall be replaced by the models appended hereto, and the model form E 122 reproduced in the same Decision shall be discontinued.

2.

Separate forms E 121 and E 127 shall be filled in for each recipient of a pension or allowance, and for each member of the family of a recipient of a pension or allowance.

3.

The competent authorities of the Member States shall make the appended forms available to the persons concerned (rightful claimants, institutions, employers, etc.). However, E 121 forms valid on the date this Decision enters into force shall remain validd until they are invalidated and/or replaced by the new model form E 121 convering only the recipient of a pension or allowance and thus not the members of their families.

4.

Each form shall be available in the official languages of the Commuity and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all persons or bodies to whom a form is addressed (rightful claimants, institutions, employers, etc.) to receive the form printed in their own language.

5.

This Decision shall be published in the Official Journal of the European Communities and shall be applicable as from 1 January 1998. In France, however, it shall not take effect until 1 January 2002.

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ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 121(1)CERTIFICATE FOR THE REGISTRATION OF PENSIONERS AND MEMBERS OF THEIR FAMILYAND THE UPDATING OF LISTSRegulation (EEC) No 1408/71: Article 28(1)(a) and Article 29(1)(a)Regulation (EEC) No 574/72: Article 29(1), (2) and (3); Article 30(1) and Article 95(4)The institution which has to draw up the certificate in accordance with Article 29(2) or Article 30(1) of Regulation (EEC) No 574/72 shouldcomplete part A of the form and issue two copies to the pensioner or family member or send them to the institution in the place of residence ifthe form was requested by that institution. Where appropriate, both copies should first be sent to the institution which has to complete sections6 and 7. On receipt of the two copies, the institution in the place of residence should complete part B and send one copy per pensioner or familymember to the institution indicated in section 7.Please complete the form in block letters, writing on the dotted lines only. The form consists of four pages.A. Notification of entitlement1. Institution of the place of residence (2)1.1 Name: ………………………………………………………………………………………………………………………………………..1.2 Identification number of the institution: ……………………………………………………………………………………………………………1.3 Address: ………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………….1.4 Reference: your E 107 form of ………………………………………………………….2. Pensioner2.1Surname(s) (3):……………………………………………………………………………Surname(s) at birth (if different):……………………………………………………………………………2.2Forename(s):……………………………………………………………………………Date of birth:…………………………………………………………………………….2.3 Address in the country of residence: ………………………………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………..2.4 Date of transfer of residence: ……………………………………………………………………………………………………………2.5 Personal identification number:……………………………………………………………………………2.6 The pensioner used to bea employed persona self-employed persona frontier worker (employed)a frontier worker (self employed)an unemployed worker3. To be completed by the institution responsible for payment of the pension3.1 The person indicated above has been entitled to a pension forold ageinvaliditysurvivoraccident at workoccupational disease3.2 since: ………………………….....................................................................4. Institution which completed section 3 (4)4.1Name: ……………………………………………………………………………………………………………………………………….4.2 Identification number of the institution: ……………………………………………………………………………………………………………4.3 Address: ………….…………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………...4.4 Stamp4.5 Date: ………………………………………………………4.6 Signature……………………………………………………………….

E 1215. Member of the pensioner's family5.1Surname(s)(3)……………………………………………………………………………………………………………………………………………………………..Surname(s) at birth (if different)(3):5.2Forename(s):……………………………………………………………………………Date of birth:…………………………………………………………………………….5.3 Address in the country of residence: ………………………………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………..5.4 Personal identification number ……………………………………………………………………………………………………………5.5 Date of transfer of residence:……………………………………………………………………………………………………………………………………………………………..6. To be completed by the institution responsible for payment of the pension or by the sickness and maternity insurance institution in thecountry responsible for payment of the pension (5)6.1 Identification number of the investigating institution: .………………………………………………………………………………………………6.2The person indicated in section 2The person indicated in section 5is entitled to sickness and maternity insurance benefits in kind as from ……………………………………………………………….6.3 The cost of the benefits to be provided in the country of residence — unless the person resides in the competent country — will beborne by us.6.4from ………………………………………………………………………………… until the certificate is cancelled6.5for one year from ……………………………………………………………………. (6)6.6this certificate invalidates the E …………. form dated ………………………………………………7.Please return the European Health Insurance card of the in section 2 or 5 mentioned person with number………………………………….. and valid till ………………………..8. Institution which completed section 6 (4)8.1 Name: ……………………………………………………………………………………………………………………………………….8.2 Identification number of the institution: ……………………………………………………………………………………………………………8.3 Address: ………….…………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………...8.4 Stamp8.5 Date: ………………………………………………………8.6 Signature:……………………………………………………………….B.Notification of registration or non-registration9.(7)9.1The person indicated in section 2The person indicated in section 5could not be registered9.2because he or she is already entitled to benefits in kind under the legislation of our country9.3other reasons: ……………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

E 12110.(7)10.1The person indicated in section 2The person indicated in section 5has been registered10.2The cost of these benefits are to be borne by you; the date from which the lump sum provided for in Article 95 of Regulation (EEC)No 574/72 should be calculated is ……………………………………………………………………………………………………………………………11. European Health Insurance Card11.1Please find attached the European Health Insurance Card with number …….. as requested in section 711.2Please indicate the measures to be applied concerning the European Health Insurance card issued to the in section 2 or 5mentioned person with number …………………………….. and valid till ……………………………………….12. Institution in the place of residence of the pensioner or family member12.1 Name: ……………………………………………………………………………………………………………………………………….12.2 Identification number of the institution: ……………………………………………………………………………………………………………12.3 Address: ………….…………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………...12.4 Stamp12.5 Date: ………………………………………………………12.6 Signature……………………………………………………………….Information for the pensioner or family memberYou should send the two copies of this form to the following insurance institution as soon as possible:inBelgium,the ‘mutualité’ (local sickness insurance fund) of your choice;in theCzech Republic, ‘the Zdravotní pojišťovna’ (sickness insurance fund) of the place of residence;inCyprus‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia). Upon application, the person concerned will be provided with a Cyprus Medical Card, without which no benefits in kind can be provided at the Government Medical Institutions;inDenmark, the municipal authority of the place of residence;inGermany, ‘the Krankenkasse’ (sickness insurance fund) of the place of residence;inGreece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a health book without which no benefits in kind can be provided;inSpain,‘the Dirección Provincial del Instituto Nacional de la Seguridad Social’ (Provincial Directorate of the National Social Security Institution) at the place of residence.inEstonia, the ‘Eesti Haigekassa’, (Health Insurance Fund);inFrance, ‘the Caisse primaire d'assurance-maladie’ (local sickness insurance fund);inIreland, the Health Board in whose area the benefit is claimed;inItaly, the‘Unità sanitaria locale’(local health administration unit) responsible for the area concerned;inLatvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency);inLithuania,the ‘Teritoriné ligoniu kasa’(Territorial Patient Fund);inLuxembourg,the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);inHungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);inMalta, the Entitlement Unit, Ministry of Health, 23. St. John Street, Valetta;in theNetherlands, any sickness fund competent for the place of residence;inAustria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence;inPoland, the regional branch of the Narodowy Fundusz Zdrowia (National Health Fund) competent for the place of residence;inPortugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (Regional Centre for Solidarity and Social Security) of the place of residence; for Madera: the Centro de Segurança Social da Madeira (Madeira Social Security Centre), Funchal; for the Azores: the Centro de Prestações Pecuniárias (Centre for Cash Benefits) of the place of residence;inSlovenia, the competent regional service of the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Slovenian Sickness Insurance Institution) at the place of residence;inSlovakia, the ‘zdravotná poist'ovňa’ (health insurance company) of the insured person's choice;inFinland, the local office of the ‘Kansaneläkelaitos’ (Social Insurance Institution);inSweden, the ‘försäkringskassan’ (Social Insurance Office) at the place of residence ;inIceland,the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;inLiechtenstein, the ‘Amt für Volkswirtschaft’ (Office of National Economy), Vaduz;inNorway, the ‘lokale trygdekontor’ (local Insurance office) at the place of residence;inSwitzerland,the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint institution under the Federal Sickness Insurance Act), Solothurn.

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) Complete only if the form is issued at the request of the institution in the place of residence. If the pensioner or family member is residentin the United Kingdom, both copies of the form should be sent directly to the Department for Work and Pensions, Pension Service,International Pension Centre, Tyneview Park, Newcastle upon Tyne.(3) Give the full surname in the order of civil status.(4) In Hungary, this section must be filled in by the sickness and maternity insurance institution.(5) In Italy, sections 6 and 7 should be completed by the ASL or Ministry of Health.(6) If the form is issued by a German, French, Hungarian, Italian or Portuguese institution and concerns a family member.(7) Complete section 8 or 9 as appropriate, and put a cross in the corresponding box.

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