Reimbursement Request

U020 - Reimbursement Request
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

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

1. Local case numbers

1.1. Local Case Number

1.1.1. Country *

1.1.2. Case number *

1.1.3. Institution

1.1.3.1. Institution ID *

1.1.3.2. Institution Name *

1.1.Local Case Number

2. General information *

2.1. Reimbursement request ID *

2.2. Number of individual claims *

2.3. Total amount requested *

2.3.1. Amount *

2.3.2. Currency *

2.4. Bank information *

2.4.1. SEPA Bank Details *

2.4.1.1. IBAN *

2.4.1.2. BIC-SWIFT

2.4.2. Bank transfer: subject or transaction reference *

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3. Individual claims *

3.1. Individual claim *

3.1.1. Person *

3.1.1.1. Person identification *

3.1.1.1.1. Family name(s) *

3.1.1.1.2. Forename(s) *

3.1.1.1.3. Date of birth *

3.1.1.1.4. Sex *

3.1.1.1.5. Family name(s) at birth

3.1.1.1.6. Forename(s) at birth

3.1.1.1.7. PIN of the person in each institution

3.1.1.1.7.1. Personal Identification Number(s) *

3.1.1.1.7.1.1. Country *

3.1.1.1.7.1.2. Personal Identification Number (PIN) *

3.1.1.1.7.1.3. Sector

3.1.1.1.7.1.4. Institution

3.1.1.1.7.1.4.1. Institution ID *

3.1.1.1.7.1.4.2. Institution Name *

3.1.1.1.7.1.Personal Identification Number(s)

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

3.1.1.1.8.1. Place of birth

3.1.1.1.8.1.1. Town *

3.1.1.1.8.1.2. Region

3.1.1.1.8.1.3. Country *

3.1.1.1.8.2. Father's family name at birth

3.1.1.1.8.3. Forename of father

3.1.1.1.8.4. Mother's family name at birth

3.1.1.1.8.5. Forename of mother

3.1.1.2. Additional information on the person

3.1.1.2.1. Nationality

3.1.2. Reimbursement request ID *

3.1.3. Sequential number of Individual claim *

3.1.4. Institution which certified insurance record *

3.1.4.1. Institution ID *

3.1.4.2. Institution Name *

3.1.5. Working periods considered *

3.1.5.1. Working period considered *

3.1.5.1.1. Start Date *

3.1.5.1.2. End Date *

3.1.5.1.Working period considered

3.1.6. Reimbursement period *

3.1.6.1. Start Date *

3.1.6.2. End Date *

3.1.7. Last payment date *

3.1.8. Requested amount for reimbursement *

3.1.8.1. Amount *

3.1.8.2. Currency *

3.1.Individual claim

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U020 - Reimbursement Request Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

U020 - Reimbursement Request
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009