15.3.2006 | EN | Official Journal of the European Union | L 77/1 ---|---|---|--- * * * DECISION No 202 of 17 March 2005 on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 101, E 102, E 103, E 104, E 106, E 107, E 108, E 109, E 112, E 115, E 116, E 117, E 118, E 120, E 121, E 123, E 124, E 125, E 126 and E 127) (Text with EEA relevance and for the EU/Switzerland Agreement) (2006/203/EC) THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS, Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community (1), pursuant to which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations, Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972 fixing the procedure for implementing Regulation (EEC) No 1408/71 on the application of social security schemes to employed persons and their families moving within the Community (2) under which it is the duty of the Administrative Commission to draw up models of documents necessary for the application of the regulations, Having regard to Decision No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127) (3), Having regard to Decision No 164 of 27 November 1996 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 101 and E 102) (4), Having regard to Decision No 166 of 2 October 1997 on the amending of forms E 106 and E 109 (5), Having regard to Decision No 168 of 11 June 1998 on the amending of forms E 121 and E 127 and the discontinuance of form E 122 (6), Having regard to Decision No 179 of 18 April 2000 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111, E 111 B, E 113 to E 118 and E 125 to E 127) (7), Having regard to Decision No 185 of 27 June 2002 amending Decision No 153 of 7 October 1993 (form E 108) (8), Having regard to Decision No 186 of 27 June 2002 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 101) (9), Whereas: (1) | The enlargement of the European Union on 1 May 2004 requires forms E 001, E 101, E 102, E 103, E 104, E 106, E 107, E 108, E 109, E 112, E 115, E 116, E 117, E 118, E 120, E 121, E 123, E 124, E 125, E 126 and E 127 to be amended. ---|--- (2) | The Agreement on the European Economic Area (EEA Agreement) of 2 May 1992, supplemented by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area. ---|--- (3) | The European Community and its Member States, and the Swiss Confederation have concluded an Agreement on the free movement of persons (Swiss Agreement) which entered into force on 1 June 2002. Annex II to the Agreement refers to Regulations (EEC) No 1408/71 and (EEC) No 574/72. ---|--- (4) | For practical reasons, the forms used in the European Union and under the EEA and Swiss Agreements should be identical, ---|--- HAS DECIDED AS FOLLOWS: 1. | Model form E 101 reproduced in Decision No 186 is replaced by the model appended hereto. ---|--- 2. | Model form E 102 reproduced in Decision No 164 is replaced by the model appended hereto. ---|--- 3. | Model form E 105 reproduced in Decision No 153 is repealed. Model forms E 001, E 103, E 104, E 107, E 112, E 120, E 123 and E 124 reproduced in Decision No 153 are replaced by the model forms appended hereto. ---|--- 4. | Model forms E 106 and 109 reproduced in Decision No 166 are replaced by the models appended hereto. ---|--- 5. | Model form E 108 reproduced in Decision No 185 is replaced by the model appended hereto. ---|--- 6. | Model forms E 115, E 116, E 117, E 118, E 125, E 126 and E127 reproduced in Decision No 179 are replaced by the models appended hereto. ---|--- 7. | Model form E 121 reproduced in Decision No 168 is replaced by the model appended hereto. ---|--- 8. | The symbol of the State to which the institution completing the form belongs, is indicated in accordance with the following: ‘BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; EL = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.’ ---|--- 9. | The competent authorities of the Member States shall make available to the parties concerned the forms according to the models appended hereto. These forms shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all addressees to receive the form printed in their own language. ---|--- 10. | This Decision, which replaces Decisions No 153, 164, 166, 168, 179, 185 and 186, shall be published in the Official Journal of the European Union. It shall apply from the first day of the month following its publication. ---|--- The Chairman of the Administrative Commission Claude EWEN * * * (1) OJ L 149, 5.7.1971, p. 2. Regulation as last amended by Regulation (EC) No 647/2005 of the European Parliament and of the Council (OJ L 17, 4.5.2005, p. 1). (2) OJ L 74, 27.3.1972, p. 1. Regulation as last amended by Regulation (EC) No 647/2005 of the European Parliament and of the Council. (3) OJ L 244, 19.9.1994, p. 22. (4) OJ L 216, 8.8.1997, p. 85. (5) OJ L 195, 11.7.1998, p. 25. (6) OJ L 195, 11.7.1998, p. 37 (7) OJ L 54, 25.2.2002, p. 1. (8) OJ L 55, 1.3.2003, p. 74. (9) OJ L 55, 1.3.2003, p. 80. * * * Text of image ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS E 001 (1) Request for information an employed person Communication of information a self-employed person Request for forms a frontier worker Reminder on a pensioner a pension claimant an unemployed person a dependant Regulation (EEC) No 1408/71: Article 84 The sending institution should complete part A and send two copies of the form to the institution to which it is addressed. The latter should complete part B and return one copy to the sending institution. The form should be used to supplement other forms or as a basis for exchanges between institutions not yet provided for in the forms currently in use. It may not be used instead of another form. Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out. Part A 1. Institution to which the form is addressed 1.1 Name: …………………………………………………………………………………………………………………………………………………. 1.2 Identification number of the institution: …………………………………………………………………………………………………………….. 1.3 Address: ………………………………………………………………………………………………………………………………………............. ……………………………………………………………………………………………………………………………………………………………. 2. Information concerning the insured person (2) 2.1 Surname(s) (3): ……………………………………………………………..…………………………………………………………..………….…. 2.2 Forename(s) (4): ………………………………………………………………………………………………………………………………………. 2.3 Previous name(s): ……………………………………………………………………………………………………………………………………. 2.4 Sex (5): ……………………………………………………………………………………………………………………………………………...…… 3. Nationality (6): …………………………………………………………………………………………………………………………………………. 4. Details of birth 4.1 Date of birth (7): ………………………………………………………………………………………………………………………………………. 4.2 Place of birth (8): ………………………………………………………………………………………………………………………………….…... 4.3 Province or department (9): ………………………………………………………………………………………………………………..……..…... 4.4 Country (10): ……………………………………………………………………………………………………………………………………………. 5. Personal identification number (11) 5.1 at the sending institution: ……………………………………………………………………………………………………………………….……. 5.2 at the institution to which the form is addressed: ………………………………………………………………………………………………..… 6. Address: …………………………………………………………………………………………..……………………………………………….….. ……………………………………………………………………………………………………………………………………………………………. 7. Information on the file 7.1 Type of benefit: …………………………………………………………………………………………………………………………………………………………….. 7.2 Reference number of the file at the sending institution: …………………………………………………………………………………………………………………………………………………………….. 7.3 Reference number of the file at the institution to which the form is addressed: …………………………………………………………………………………………………………………………………………………………….. Text of image E 001 8. Dependant (12) 8.1 Surname(s) (3): …………………................................................................................................................................................................... 8.2 Forename(s) (4): ……………………………………………………………………………………………………………………………………….. 8.3 Previous name (s): ……………………………………………………………………………………………………………………………………... 8.4 Place of birth (8): Date of birth: ……………………………………………………………………. ……………………………………………………………………………….. 8.5 Sex: …………………………………………… Nationality (6): …………………………………………………………………………………….. 8.6 Personal identification number (11): at the sending institution: ……………………………………………………………………………………………………………………….……. at the institution to which the form is addressed: ………………………………………………………………………………………………….. 8.7 Address: …………………………………………………………………………………………………………………………………….…………. ……………………………………………………………………………………………………………………………………………………………... 9. Request Reminder of request dated: ………………………………………………… With reference to the person named in section 2 8 please send 9.1 the following form(s): ……………………………………………………………………………………………………………………………… 9.2 the following document(s): ………………………………………………………………………………………………………………...……... ……………………………………………………………………………………………………………………………………………………..… 9.3 the following information: …………………………………………………………………………………………………………..................… ……………………………………………………………………………………………………………………………………………………..… 9.4 Reason for request: ………………………………………………………………………………………………………………………………..…. 10. Change in circumstances: the following changes have taken place ………………………………………………………………………………………………………………………………………………………..….. ……………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………..... ……………………………………………………………………………………………………………………………………………………………. 11. Miscellaneous information ………………………………………………………………………………………………………………………………………………………….... ………………………………………………………………………………………………………………………………………………………..….. ………………………………………………………………………………………………………………………………………………………..….. ………………………………………………………………………………………………………………………………………………………….... 12. Institution completing part A 12.1 Name: ………………………………………………………………………………………………………………………………………………..…. 12.2 Identification number of the institution: ………………………………………………………………………………………………………………. 12.3 Address: …………………………………………………………………………………………………………………………………………………. 12.4 Stamp 12.5 Date: ………………………………………………………………… 12.6 Signature: ………………………………………………………………… Text of image E 001 Part B 13. In response to your request of ………………………………… we are enclosing: 13.1 the following form(s): ………………………………………………………………………………………………………………….. 13.2 the following document(s): ………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………… 13.3 the following information: ……………………………………………………………………………………………………....…..…. …………………………………………………………………………………………………………………………………………………….…..….. 14. In response to your request of ………………………………….. we regret that we are unable to forward: 14.1 the following form(s): ……………………………………………………………………………………………………………………......….… 14.2 the following document(s): …………………………………………………………………………………………………………..……...….… 14.3 the following information: ……………………………………………………………………………………………………...………………… 14.4 Reasons: …………………………………………………………………………………………………………………………………...……… …………………………………………………………………………………………………………………………………………………..……….. …………………………………………………………………………………………………………………………………………………..……….. 15. Miscellaneous information …………………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………….. 16. With reference to your form transmitted on …………………………………………………………………………………………………..… we acknowledge receipt of the information contained in section 10 17. Institution, completing part B 17.1 Name: …………………………………………………………………………………………………………………………..………………………. 17.2 Identification number of the institution: ………………………………………………………………………………………………………………. 17.3 Address: ……………………………………………………………………………………………………………………………….………………. ……………………………………………………………………………………………………………………………………………………………. 17.4 Stamp 17.5 Date: ………………………………………………………………… 17.6 Signature: ………………………………………………………………… Text of image E 001 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) Lines 2.1 to 2.4 identifying the insured person should be completed where appropriate. (3) Give all surnames in the order of civil status. (4) Give all forenames in the order of civil status. (5) Put "M" for male or "F" for female. (6) Where appropriate, give the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state "None". (7) The day and month should each be expressed by two digits, and the year by four digits (e.g. 1 August 1921 = 01.08.1921). (8) For French cities comprising several arrondissements, please give the number of the arrondissement (e.g. Paris 14). In the case of Portuguese districts, please also state the parish and local authority. (9) This information is obligatory for insured persons of Spanish, French or Italian nationality. Depending on the country, the entry should consist of the territorial division in which the place of birth is located (in the case of France, for example, if the commune of birth is Lille, the department of birth should be given as "Nord" followed by the department code, if the insured person knows it, in this case "59". The complete entry should therefore read "Nord 59"). In the case of persons born in Spain, state only the province. (10) Symbol of the insured person's country of birth in accordance with note (1). (11) For the purpose of Italian institutions, give the "fiscal code". For the purpose of Maltese institutions, give the Identity Card number in case of Maltese nationals, or the Maltese Social security number in case of a non- Maltese national. For the purpose of Slovak institutions, give the Slovak birth number if applicable. (12) Complete where appropriate. * * * Text of image ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS E 101 (1) CERTIFICATE CONCERNING THE LEGISLATION APPLICABLE Regulation (EEC) No 1408/71: Article 13(2)(d); Article 14(1)(a), (2)(a) and (2)(b); Article 14a(1)(a), (2) and (4); Article 14b(1), (2) and (4); Article 14c(a); Article 14e; Article 17 Regulation (EEC) No 574/72: Article 11(1); Article 11a(1); Article 12a(2)(a), (5)(c) and (7)(a); Article 12b Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out. 1. Employed person Self-employed person 1.1 Surname(s) (2): ………………………………………………………………………………………………………………………………………… 1.2 Forename(s) (3): ………………………………………………………………………………………………………………………………………… 1.3 Previous name (s): …………………………………………………………………………………………………………………………………… 1.4 Date of birth: Nationality: ………………………………………………… …………………………………………………………………………………………… 1.5 Permanent address Street: ………………………………………………………… No: ………………………………… PO Box: ……………………………… Town: ………………………………………………………… Postal code: ……………………… Country: …………………………… 1.6 Personal identification number (4): …………………………………………………………………………….………………………………… 2. Employer Activity as a self-employed person 2.1 Name or business name: …………………………………………………………………………………………………………………………………………………………… 2.2 Identification number (5): ……………………………………………………………………………………………………………………………… 2.3 The employer is a recruitment agency Yes No 2.4 Permanent address Telephone: ………………………………… Fax: ………………………………… E-mail: ……………………………………… Street: ………………………………………………………… No: ……………………………… PO Box: ……………………………… Town: ………………………………………………………… Postal code: …………………… Country: ……………………………… 3. The aforementioned insured person 3.1 has been employed by the employer mentioned above since ……………………………………………………………………………… has been pursuing an activity as a self-employed person since …………………………………………………………………………… in …………………………………………………………………………………………………………………………………………………… 3.2 is being posted or will pursue an activity as a self-employed person for a period probably lasting from ………………………………………………………………….. to ……………………………………………………………………… 3.3 in the firm(s) mentioned below on the ship mentioned below 3.4 Name(s) or business name(s) of the firm or ship: …………………………………………………………………………………………………………………………………………………………… 3.5 Address(es) Street: …………………………………………………………… No: ……………………………… PO Box: ……………………………… Town: …………………………………………………………… Postal code: ……………………… Country: ……………………………… Street: …………………………………………………………… No: ……………………………… PO Box: ……………………………… Town: …………………………………………………………… Postal code: ……………………… Country: ……………………………… 3.6 Identification number (5): …………………………………………………………………………………………… …………………………… Text of image E 101 4. Who pays the wage and social security contributions of the employed posted person? 4.1 The employer referred to in point 2 4.2 The firm referred to in point 3.4 4.3 Other if so, give the name ……………………………………………………………………………………………………………………………………………………… and Address Street: …………………………………………………………… No: ……………………………… PO box: ……………………………… Town: ………………………………………………………… Postal code: …………………… Country: ……………………………… 5. The insured person remains subject to the legislation of the country: (1) 5.1 in accordance with Article: 13(2)(d) 14(1)(a) 14(2)(a) 14(2)(b) 14a(1)(a) 14a(2) 14a(4) 14b(1) 14b(2) 14b(4) 14c(a) 14e 17 of Regulation (EEC) No 1408/71 5.2 from ………………………………………………………… to ……………………………………………………………… 5.3 for the duration of the activity (see the letter from the competent authority or designated body in the country of employment which entitles the insured person to remain subject to the legislation of the Sending State of …………………………………………………………… reference …………………………………………………) 6. Competent institution whose legislation is applicable 6.1 Name: ……………………………………………………………………………………………………………………………………………… 6.2 Identification number of the institution: ……………………………………………………………………………………………………………… 6.3 Address ………………………………………………………………………………………………………………………………………………… Telephone: ………………………………… Fax: ………………………………… E-mail: ……………………………………… Street: …………………………………………………………… No: ……………………………… PO Box: ……………………………… Town: ………………………………………………………… Postal code: …………………… Country: …………………………… 6.4 Stamp 6.5 Date: ………………………………………………………………… 6.6 Signature: ………………………………………………………………… Text of image E 101 INSTRUCTIONS The designated institution of the Member State to whose legislation the worker is subject should fill in the form at the request of the worker or his employer and return it to the applicant. If the worker is posted to Belgium, Denmark, Germany, France, the Netherlands, Austria, Finland, Sweden, or Iceland, the institution should also send a copy to: in Belgium, in the case of employed persons to the ‘Office national de sécurité sociale/Rijksdienst voor Sociale Zekerheid’ (National Social Security Office), Brussels; in the case of self-employed persons to the ‘Institut national d'assurances sociales pour travailleurs indépendants/Rijksinstituut voor sociale verzekering der zelfstandigen’ (National Social Insurance Institute for the Self-Employed), Brussels; in the case of seamen, to the ‘Caisse de secours et de prévoyance en faveur des marins: de Hulp- en Voorzorgskas voor Zeevarenden’ (Relief and Welfare Fund for Mariners), Antwerp; or, in the case of civil servants, to the ‘Service des Relations internationales du S.P.F. Sécurité sociale’ (International Relations Department, Social Affairs Ministry); in Denmark, to ‘Den Sociale Sikringsstyrelse’ (The National Social Security Agency); in Germany, to the Deutsche Rentenversicherung-Bund (German Federal Pension Insurance), 97041 Würzburg; in France, to the ‘Centre des liaisons européennes et internationales de sécurité sociale (Cleiss)’ (Centre for European and International Liaison on Social Security), Paris; in the Netherlands, to the ‘Sociale Verzekeringsbank’ (Social Insurance Bank), Amstelveen; in Austria, to the "Hauptverband der österreichischen Sozialversicherungsträger" (Main Association of Austrian Social Insurance Institutions); in Finland, to the ‘Elaketurvakeskus’ (Finnish centre for Pensions), Helsinki; in Sweden, to Försäkringskassan, Huvudkontoret (Swedish Social Insurance Agency, Head Office), Stockholm; in Iceland, to the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik. Information for the insured person Before you leave the country where you are insured to go to another Member State to work, make sure you have the document which entitles you to receive the necessary benefits in kind (e.g. medical care, medication, treatment in hospital, etc.) in the country where you are working. If you are going to be living in the country in which you are working, ask your sickness insurance institution for an E 106 form and submit it as soon as possible to the competent sickness insurance institution of the place where you are going to work. If you are staying temporarily in the country in which you are going to work, ask your sickness insurance institution for the European health insurance card. You must show this card to your care provider if you need benefits in kind during your stay. Information for employers A Member State which receives a request for the application of the aforementioned Article 14(1), Article 14b(1) or Article 17 of Regulation (EEC) No 1408/71 shall duly inform the employer and the worker concerned of the conditions under which the posted worker may continue to be subject to its legislation. The employer shall be informed of the possibility of checks throughout the period of posting so as to ascertain that this period has not come to an end. Such checks may relate, in particular, to the payment of contributions and the maintenance of the direct relationship. Moreover, the employer of the posted worker shall inform the competent institution of the sending State of any change that has occurred during the period of posting, in particular: if the posting applied for has not taken place or if the extension of the posting applied for has not taken place, if the posting has been interrupted, unless this interruption of the worker's activities on behalf of the undertaking in the country of employment is of a purely temporary nature, if the posted worker has been assigned by his employer to another undertaking in the State of employment. In the first two cases, he/she shall return this form to the competent institution of the sending State. Information for the institution of the place of stay If the person involved produces the proper document (European health insurance card or form E 106), the insurance institution in the country of stay will also provide him provisionally with benefits in the event of an accident at work or an occupational disease. If in such a case the institution requires form E 123, it should apply as soon as possible: in Belgium, for employed persons and as regards an occupational disease, to the ‘Fonds des maladies professionnelles/Fonds voor Beroepsziekten’ (Occupational Diseases Fund), Brussels, and, as regards accidents at work, to the insurance company designated by the employer; in the Czech Republic, to the sickness insurance fund with which the person concerned is insured; in Denmark, to ‘Arbejdsskadestyrelsen’ (National Board of Industrial Injuries), Copenhagen; in Germany, to the competent ‘Berufsgenossenschaft’ (Accident Insurance Institution); in Estonia, to the ‘Sotsiaalkindlustusamet’ (Social Insurance Board), Tallinn; in Spain, to the ‘Dirección Provincial del Instituto Nacional de Seguridad Social’ (Provincial Directorate of the National Social Security Institution); in Ireland, to the Department of Health, Planning Unit, Dublin 2; in Italy, to the competent provincial office of the ‘Istituto nazionale per I'assicurazione contro gli infortuni sul lavoro’ (INAIL))National Institute for Insurance against Accidents at Work); in Latvia, to the ‘Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency), Riga; in Lithuania, to the ‘Teritorinė ligoniu kasa’ (Regional Sickness Insurance Fund); in Luxembourg, to the ‘Association d'assurance contre les accidents’ (Accident Insurance Association); in Malta, to the ‘Diviżjoni tas-Saħħa’, Triq il-Merkanti, Valletta CMR 01; in the Netherlands, to the competent sickness insurance institution; in Austria, to the competent accident insurance institution; in Poland, to the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund); in Portugal, to the ‘Centro Nacional de Proteccao contra os Riscos Profissionais’ (National Centre for Protection against Occupational Risks), Lisbon; in Slovakia, to the health insurance company of the insured person or the Social Insurance agency, Bratislava; in Finland, to the ‘Tapaturmavakuutuslaitosten Liitto’ (Federation of Accident Insurance Institutions), Bulevardi 28, 00120 Helsinki; in Sweden, to the ‘Forsakringskassan’ (Local Social Insurance Office); in all other Member States, to the competent sickness insurance institution; in Iceland, to the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik; in Liechtenstein, to the ‘Amt fur Volkswirtschaft’ (Office of National Economy), Vaduz; in Norway, to the ‘Folketrygdkontoret for Utenlandssaker’ (National Office for Social Insurance Abroad), Oslo; Text of image E 101 in Switzerland, for employed persons, to the employer's accident insurance institution; for self-employed persons, to the accident insurance institution of the person concerned. Where the worker is covered by the French social security scheme, the fund which is competent to recognise entitlement to benefits is his insurance fund, which may not be the one appearing on form E 101. It will be necessary, where appropriate, to request the European health insurance card or form E 123 from the fund of the worker's place of habitual residence. Where a self-employed person is covered by a Finnish or Icelandic social security scheme it will always be necessary to request form E 123. Where a worker covered by an Icelandic social security scheme suffers an accident at work or contracts an occupational disease, the employer must always duly notify the competent institution. NOTES (1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland. (2) Give all surnames in the order of civil status. (3) Give all forenames in the order of civil status. (4) For workers subject to Spanish law, indicate the social security number. For the purpose of Maltese institutions, give the Identity Card number in case of Maltese nationals, or the Maltese Social security number in case of a non- Maltese national. in the case of persons being subject to Polish legislation, please indicate the PESEL and NIP numbers or, failing that, the series and the number of the identity card or passport. For the purpose of Slovak institutions, give the Slovak birth number if applicable. (5) Please give as much information as possible to facilitate identification of the employer or the firm of the self-employed person. In the case of a ship, indicate its name and its registration number. Belgium: indicate, in the case of employed persons, the business number (numéro d'entreprise/ondernemingsnummer/Unternehmensnummer) and, in the case of self-employed persons, the VAT number. Czech Republic: indicate the identification number (IČ). Denmark: indicate the CVR number. Germany: indicate the "Betriebsnummer des Arbeitgebers". Spain: indicate the "Código de Cuenta de Cotización del Empresario CCC" (employer's contribution account number). France: indicate the SIRET number. Italy: indicate the company's registration number where possible. Luxembourg: indicate the employer's social security registration number and, for self-employed persons, the social security number (CCSS). Hungary: indicate the employer's social security registration number or, for self-employed persons, the identification number of the private company. Poland: indicate the NUSP number, where there is one, or the NIP and REGON numbers. Slovakia: indicate the identification number (IČO). Slovenia: indicate the registration number of the employer or self-employed person. For workers subject to Finnish legislation on occupational accidents, please indicate the name of the competent accident insurance institution. Norway: indicate the organisation number. * * * Text of image ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS E 102 (1) EXTENSION OF TERM OF POSTING OR OF ACTIVITY AS SELF-EMPLOYED PERSON Regulation (EEC) No 1408/71: Article 14(1)(b); Article 14a(1)(b); Article 14b(1) and (2) Regulation (EEC) No 574/72: Article 11(2) and 11a(2) Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out out. A. To be completed by the employer or the self-employed person 1. Institution to which the form is addressed (2) 1.1 Name: …………………………………………………………………………………………………………………………………………………………….. 1.2 Identification number of the institution: ………………………………………………………………………………………………………………. 1.3 Address: ………………………………………………………………………………………………………………………………………………… Tel.: ……………………………………………………………. Fax: ………………………………………………………………..…… Street: ………………………………………………………….. No: ………………………………… PO Box: ……………………………… Town: ………………………………………………………… Postcode: …………………….. Country: ……………………………… 2. Employed person Self-employed person 2.1 Surname(s) (3): ……………………………………………………………………………………………………………………………………………. 2.2 Forename(s) (4): ………………………………………………………………………………………………………………………………………….. 2.3 Previous name(s): ……………………………………………………………………………………………………………………………………… 2.4 Date of birth: Nationality: ……………………………………………….. ………………………………………………………………………………………………………. 2.5 Permanent address: Street: ………………………………………………………….. No: ………………………………… PO Box: ………………………………. Town: ………………………………………………………… Postcode: …………………….. Country: ……………………………… 2.6 Personal identification number (5): ………………………………………………………………………………………………………………….... 3. The abovementioned insured person has been posted is carrying out an activity as a self-employed person in accordance with Article: 3.1 14(1)(a) 14a(1)(a) 14b(1) 14b(2) of Regulation (EEC) No 1408/71 3.2 for the period from ……………………………………………………………. to ……………………………………………………………… 3.3 to/in the undertaking(s) specified below to/on the ship specified below 3.4 Name of firm or ship …………………………………………………………………………………………………………………………………………………………….. 3.5 Address: …………………………………………………………………………………………………………………………………………………. Tel.: ……………………………………………………………. Fax: …………………………………………………………… Street: ………………………………………………………….. No: ……………………………….. PO Box: ……………………………… Town: ………………………………………………………… Postcode: ……………………. Country: ……………………………… 3.6 Identification number (6): ……………………………………………………………………………………………………………………….……… Text of image E 102 4. The insured person was in possession of a certificate concerning the legislation applicable (an E 101 form) 4.1 issued by the following institution: Name: …………………………………………………………………………………………………………………………………………. Street: …………………………………………………………… No: ……………………………….. PO Box: ……………………………… Town: ………………………………………………………… Postcode: ……………………. Country: ……………………………… 4.2 on …………………………………………………………………..… and expiring on ……………………………………………… 5. We request that you continue to apply the legislation of the country (1) 5.1 for the period from ……………………………………………… to ………………………………………………….. (7) 6. Employer Activity as self-employed person 6.1 Name of employer or firm: …………………………………………………………………………………………………………………………………………………………….. 6.2 Identification number (6): …………………………………………………………………………………………………………………………………………………………….. 6.3 Address: ………………………………………………………… …. Tel.: ………………………………………………………… …. Fax: ………………………………………………………………….…. Street: ………………………………………………………….. No: ……………………………….. PO Box: ………………………………. Town: ………………………………………………………… Postcode: ……………………. Country: ……………………………… 6.4 Stamp 6.5 Date: ………………………………………………………………… 6.6 Signature: ………………………………………………………………… B. To be completed by the competent authority or the designated body of the country of employment (8) 7. We declare that: 7.1 it is agreed it is not agreed that the social security legislation of the country still applies to the insured person mentioned in box 2 (1) 7.2 for the period from ………………………………………………………. to ……………………………………………………………… 8. Competent authority or designated body in the country of employment 8.1 Name: …………………………………………………………………………………………………………………………………………………………… 8.2 Identification number of the institution: ……………………………………………………………………………………………………………..…. 8.3 Address: .……………………………………………………………………………………………………………………………………………..… Tel.: ……………………………………………………………. Fax: …………………………………………………………………..... Street: ………………………………………………………….. No: ……………………………….. PO Box: ………………………………. Town: ………………………………………………………… Postcode: ……………………. Country: ……………………………… 8.4 Stamp 8.5 Date: ………………………………………………………………… 8.6 Signature: ………………………………………………………………… Text of image E 102 INSTRUCTIONS Information for the employer or the self-employed person (a) The employer or the self-employed person should complete part A of the form, providing 4 copies, which he should send to the competent authority or to the designated body in the country to which the worker has been posted or is carrying out an activity as a self-employed person, i.e.: in Belgium, in the case of employed persons the ‘Office national de sécurité sociale/Rijksdienst voor sociale zekerheid’ (national office of social security); in the case of self-employed persons the ‘Institut national d'assurances sociales pour les travailleurs indépendants/Rijksinstituut voor sociale verzekering der selfstandigen’ in Brussels; in the case of seamen the ‘Caisse de Secours et de Prévoyance des marins/Hulp-en Voorzorgskas voor Zeevarenden’ in Antwerp; in the Czech Republic, the ‘Česká správa sociálního zabezpečení’ (Czech social security administration) in Prague; in Denmark, ‘Den Sociale Sikringsstyrelse’ (National Social Security Agency) in Copenhagen; in Germany, the ‘Deutsche Verbindungsstelle Krankenversicherung — Ausland’ (German Liaison Agency Health Insurance — International) in Bonn; in Estonia, the ‘Sotsiaalkindlustusamet’ (Social Insurance Board) in Tallinn; in Greece, for employed persons, the regional or local branch of the Social Insurance Institute (IKA-ETAM); for mariners, the Seamen's Pension Fund (NAT); for self-employed persons, the institution designated for each professional category under Annex 10 — F. GREECE of Regulation (EEC) No 574/72; in Spain, the ‘Tesorería General de la Seguridad Social — Ministerio de Trabajo y Asuntos Sociales’ (central treasury for social security — Ministry of Labour and Social Affairs) in Madrid; in France, the ‘Centre des liaisons européennes et internationales de sécurité sociale (Cleiss)’ (centre for European and international social security liaison); in Ireland, the Department of Social and Family Affairs, PRSI Special Collections Section, Government Buildings, Cork Rd, Waterford; in Italy, the ‘Ministerio del Lavoro e delle Politiche Sociali’ (Ministry of Labour and Social Policy) in Rome; in Latvia, the ‘Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency); in Lithuania, the ‘Valstybinio socialinio draudimo fondo valdyba’ (national social insurance fund board); in Luxembourg, the ‘Centre commun de la sécurité sociale’ (common social security centre) in Luxembourg; in Hungary, the ‘Országos Egészségbiztosítási Pénztár’ (national sickness insurance fund) in Budapest; in Malta, the ‘Dipartiment tas-Sigurta' Soċjali’ (social security department), 38, Triq l-Ordinanza, Valletta, CMR 01 in the Netherlands, the ‘Sociale Verzekeringsbank’ (social insurance bank) in Amstelveen; in Austria, the ‘Bundesministerium für soziale Sicherheit, Generationen- und Konsumentenschutz’ (Federal Ministry of Social Security, Generations and Consumer Protection) in Vienna; in Poland, the ‘Zakład Ubezpieczeń Społecznych (ZUS)’ (Social Insurance Institution) in Warsaw; in Portugal, for metropolitan Portugal: the ‘Departamento de Relações Internacionais de Segurança Social’ (Department of International Relations and Social Security) in Lisbon; for Madeira: the "Secretario Regional dos Assuntos Sociais" (regional secretary for social affairs) in Funchal; for the Azores: the "Direcção Regional de Segurança Social" (regional social security directorate) in Angra do Heroismo; in Slovenia, the ‘Ministrstvo za delo, družino in socialne zadeve’ (Ministry of Labour, Family and Social Affairs) in Ljubljana; in Slovakia, the ‘Sociálna poist'ovňa’ (Social Insurance Agency) in Bratislava; in Finland, the ‘Eläketurvakeskus’ (Finnish Centre for Pensions) in Helsinki; in Sweden, the Försäkringskassan, Huvudkontoret (Swedish Social Insurance Agency, Head Office) in Stockholm; in the United Kingdom, the Inland Revenue, Centre for Non-Residents, Benton Park View, Newcastle upon Tyne, NE98 1ZZ; in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute) in Reykjavik; in Liechtenstein, the ‘Amt für VoIkswirtschaft’ (office of national economy) in Vaduz; in Norway, the ‘Folketrygdkontoret for utenlandssaker’ (national insurance office for social insurance abroad) in Oslo; in Switzerland, to whichever ‘Caisse de Compensation AVS’ (old-age and survivors' insurance fund) would be competent for the employed or self- employed worker if Swiss legislation were applicable. (b) Two copies of the form, with part B completed, will be sent to the employer or the self-employed person. The employer will send one of these copies to the employed person. (c) A Member State which receives a request for an application of the aforementioned Articles 14(1) or 14b(1) of Regulation (EEC) No 1408/71 shall duly inform the employer and the worker concerned of the conditions under which the worker may continue to be subject to its legislation. The employer shall thus be informed of the possibility of checks throughout the period of posting so as to ascertain that this period has not come to an end. Such checks may relate, in particular, to the payment of contributions and the maintenance of the direct relationship. Text of image E 102 Moreover, the employer of the posted worker shall inform the competent institution of the sending State of any change that has occurred during the period of posting, in particular: if the posting applied for has not taken place or if the extension of posting applied for has not taken place, if this posting has been interrupted, unless this interruption of the worker's acitivities for the undertaking in the State of employment is of a purely temporary nature, if the posted worker has been assigned by his employer to another undertaking in the State of employment. In the first two cases, the employer shall return this form to the competent institution of the sending State. 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 = the Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland. (2) See the information given at point (a) under "Information for the employer or the self-employed person". (3) Give all surnames in the order of civil status. (4) Give all forenames in the order of civil status. (5) For workers subject to Belgian law, indicate the national social security number (NISS). For workers subject to Czech law, indicate the Czech birth number. For workers subject to Danish law, indicate the CPR number. For workers subject to Spanish law, indicate the social security number. For workers subject to Italian law, indicate the Italian fiscal code number. For workers subject to Lithuanian law, indicate the national registration number and the national social security certificate number. For workers subject to Luxembourg law, indicate the worker's social security number (CCSS). For workers subject to Maltese law, indicate the Maltese social security number. For workers subject to Netherlands' law, indicate the SOFI number. For workers subject to Polish law, indicate the PESEL and NIP numbers or, failing that, the series and the number of the identity card or passport. For workers subject to Slovenian law, indicate the ZZZS number. For workers subject to Slovak law, indicate the Slovak birth number. (6) Please state as much information as possible which may be used in order to identify the employer or the firm of the self-employed person. In the case of a ship indicate the name of the ship and the ship registration number. For Belgium, indicate in the case of employed persons, the business number (numéro d'entreprise/ondernemingsnummer/Unternehmensnummer) and, in the case of self-employed persons, the VAT registration number. For the Czech Republic, indicate the identification number (IČ). For Denmark, indicate the CVR number. For Germany, indicate the ‘Betriebsnummer des Arbeitgebers’. For Spain, indicate the ‘Código de Cuenta de Cotización del Empresario CCC’ (employer's contribution account number). For France, indicate the SIRET number. For Luxembourg, indicate the employer's social security registration number and, for self-employed workers, the social security number (CCSS). For Hungary, indicate the employer's social security registration number and, for self-employed workers, the private-company identification number. For Malta, in the case of Maltese nationals indicate the identity card number and in the case of non-Maltese nationals indicate the Maltese social security number. For Poland, indicate the NUSP number if there is one, or the NIP and REGON numbers, at point 3.6 and the PESEL and NIP numbers or, failing that, the series and the number of the identity card or passport, at point 6.2. For Slovenia, indicate the registration number of the employer or self- employed person. For Slovakia, indicate the company identification number (IČO). For workers subject to Finnish occupational accident law, indicate the name of the competent accident insurance institution. For Norway, indicate the number of the organisation. (7) This period must not be more than 24 months from the date of the commencement of posting or of the self-employed activity. (8) Two copies should be returned to the claimant and one copy sent to the designated institution in the country in which the undertaking has its registered office. * * * Text of image ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS E 103 (1) EXERCISING THE RIGHT OF OPTION Regulation (EEC) No 1408/71: Article 16(2) and (3) Regulation (EEC) No 574/72: Article 13(2) and (3); Article 14(1) and (2) After completing part A of the form in accordance with points a) and b) of the instructions, the insured person should hand the form in or forward it in accordance with points a) and c) of the instructions. The institution receiving the form should complete part B and return one copy to the insured person. Please complete this form in block letters (in triplicate), writing on the dotted lines only. It consists of three pages, none of which may be left out. A. Option 1. The undersigned 1.1 Surname(s) (2): ……………………………………………………………………………………………………………………………………… 1.2 Forename(s) (3): ……………………………………………………………………………………………………………………………………… 1.3 Previous name(s): …………………………………………………………………………………………………………………………………… 1.4 Date of birth: …………………………………………………………….…………... 1.5 Nationality: ………………………………………………….……………….……… 1.6 Personal identification number (4):………………………………………………………………………………………………………….. 2. Employed since: ..…………………………………………….………………………………………………………………….…………………. 2.1 (4) as: ……………………………………………………………….. by the diplomatic mission or consulate post named hereafter: …………………………………………………………………………………………………………………………………………..…. 2.2 (4) as: ……………...……………………………………………………………………………………………………………………….... in the private staff of the following employer (5): ………………………………………………………………………………………….…….. agent of the diplomatic mission or consular post named hereafter: …………………………………………………………….……………. …………………………………………………………………………………………………………………………………………………………... 2.3 as a member of the auxiliary staff of the European Communities 3. Hereby opts to be subject to the social security legislation 3.1 (6) of the State of which he is a national 3.2 (6) of the State to whose legislation he was last subject, i.e. the legislation of Belgium Czech Republic Denmark Germany Estonia Greece Spain France Ireland Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Slovenia Portugal Slovakia Finland Sweden United Kingdom Iceland Liechtenstein Norway Switzerland 4. Place and date: .………………………………….……………….…….……………………….. 5. Signature: …………………..………………………………………......................................................... 6. Authority of the European Communities which has concluded the contract with the member of the auxiliary staff 6.1 Name: ...……………………………………………….………………………………………………………………..………………….. 6.2 Address: ..………………………………………………………………………………………………………………………………….……...… ………………..…………………………………………………………………………………………………………………................................. 6.3 Stamp 6.4 Date: ..…………………..……………………………….. 6.5 Signature: ……………………………….……………………………... Text of image E 103 B. Declaration 7. We have taken note of the fact that the person mentioned in box 1 is subject to the legislation of (6) Belgium Czech Republic Denmark Germany Estonia Greece Spain France Ireland Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Slovenia Slovakia Finland Sweden United Kingdom Iceland Liechtenstein Norway Switzerland 7.1 As from: ……………………………………. 7.2 For the period during which he is engaged in the employment indicated in part A of this form (7) 8. Institution designated by the competent authority 8.1 Name: ………………………………………………………………………………………………………………………………………. 8.2 Identification number of the institution:
