Request for Estimation on costs / Request for Administrative Check

H130 - Request for Estimation on costs / Request for Administrative Check
Articles 36(3), 21, 82 of Regulation (EC) No 883/2004, 33(1), 27(5), (10), 87(1), (3) of Regulation(EC) No 987/2009

SED API version: 0.15.3 build preview 1
Model version: 4.1.0

1. Person *

1.1. Person Identification *

1.1.1. Family name(s) *

1.1.2. Forename(s) *

1.1.3. Date of birth *

1.1.4. Sex *

1.1.5. Family name(s) at birth

1.1.6. Forename(s) at birth

1.1.7. PIN of the person in each institution

1.1.7.1. Personal Identification Number(s) *

1.1.7.1.1. Country *

1.1.7.1.2. Personal Identification Number (PIN) *

1.1.7.1.3. Sector

1.1.7.1.4. Institution

1.1.7.1.4.1. Institution ID *

1.1.7.1.4.2. Institution Name *

1.1.7.1.Personal Identification Number(s)

1.1.8. If PIN not provided for every institution, please provide

1.1.8.1. Place of birth

1.1.8.1.1. Town *

1.1.8.1.2. Region

1.1.8.1.3. Country *

1.1.8.2. Father's family name at birth

1.1.8.3. Forename of father

1.1.8.4. Mother's family name at birth

1.1.8.5. Forename of mother

1.2. Additional information on the person

1.2.1. Nationality

2. Addresses of the insured person

2.1. Address of the insured person

2.1.1. Type of address

2.1.2. Address

2.1.2.1. Street

2.1.2.2. Building Name

2.1.2.3. Town *

2.1.2.4. Postal Code

2.1.2.5. Region

2.1.2.6. Country *

2.1.Address of the insured person

3. Please fill in the following section if the request concerns the sickness sector

3.1. Person Status *

4. Please fill in the following section only if the request concerns an accident at work or an occupational disease:

4.1. This SED is related to *

4.2. Dated *

4.3. Accident / disease code

4.4. Accident / disease coding system

4.5. Consequences of the accident / kind or short description of the disease

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4.6. Status of the person

4.7. Please fill in the following if "Status of the person" = "Other" :

4.7.1. Other

4.8. Employer *

4.8.1. Name *

4.8.2. Identification numbers

4.8.2.1. Identification number

4.8.2.1.1. Number *

4.8.2.1.2. Type *

4.8.2.1.Identification number

4.8.3. Address

4.8.3.1. Street

4.8.3.2. Building Name

4.8.3.3. Town *

4.8.3.4. Postal Code

4.8.3.5. Region

4.8.3.6. Country *

5. Period concerned *

5.1. The Administrative Check concerns the period of incapacity for work *

5.1.1. Period *

5.1.1.1. Start Date *

5.1.1.2. End Date *

6. Nature of request *

6.1. We ask you to *

7. We agree to cover the costs of the administrative checks *

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8. Attachments

8.1. Predefined Documents

8.2. Other Documents Attached

8.2.1. Other Document

8.2.1.1. Document

8.2.1.Other Document

9. Additional information

9.1. Additional information

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H130 - Request for Estimation on costs / Request for Administrative Check Articles 36(3), 21, 82 of Regulation (EC) No 883/2004, 33(1), 27(5), (10), 87(1), (3) of Regulation(EC) No 987/2009

H130 - Request for Estimation on costs / Request for Administrative Check
Articles 36(3), 21, 82 of Regulation (EC) No 883/2004, 33(1), 27(5), (10), 87(1), (3) of Regulation(EC) No 987/2009