Request Insurance Record

U001 - Request Insurance Record
Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009

SED API version: 0.14.2 PREVIEW build 3
Model version: 4.0.16

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. Person *

2.1. Person identification *

2.1.1. Family name(s) *

2.1.2. Forename(s) *

2.1.3. Date of birth *

2.1.4. Sex *

2.1.5. Family name(s) at birth

2.1.6. Forename(s) at birth

2.1.7. PIN of the person in each institution

2.1.7.1. Personal Identification Number(s) *

2.1.7.1.1. Country *

2.1.7.1.2. Personal Identification Number (PIN) *

2.1.7.1.3. Sector

2.1.7.1.4. Institution

2.1.7.1.4.1. Institution ID *

2.1.7.1.4.2. Institution Name *

2.1.7.1.Personal Identification Number(s)

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

2.1.8.1. Place of birth

2.1.8.1.1. Town *

2.1.8.1.2. Region

2.1.8.1.3. Country *

2.1.8.2. Father's family name at birth

2.1.8.3. Forename of father

2.1.8.4. Mother's family name at birth

2.1.8.5. Forename of mother

2.2. Additional information on the person

2.2.1. Nationality

3. Person's current address *

3.1. Address details *

3.1.1. Street

3.1.2. Building Name

3.1.3. Town *

3.1.4. Postal Code

3.1.5. Region

3.1.6. Country *

3.2. Contact information

3.2.1. Telephone Numbers

3.2.1.1. Telephone Number

3.2.1.1.1. Type

3.2.1.1.2. Number *

3.2.1.1.Telephone Number

3.2.2. Email Addresses

3.2.2.1. Email Address

3.2.2.1.1. Email Address

3.2.2.1.Email Address

4. Last address in state of former insurance

4.1. Street

4.2. Building Name

4.3. Town *

4.4. Postal Code

4.5. Region

4.6. Country *

5. Reference period *

Fixed period*
Open period*

5.1.1. Start date *

5.1.2. End date *

5.2.1. Type of Open Period *

5.2.2. Start date *

6. Periods of insurance, employment or self employment

6.1. Period of insurance, employment or self employment

6.1.1. Period *

Fixed period*
Open period*

6.1.1.1.1. Start date *

6.1.1.1.2. End date *

6.1.1.2.1. Type of Open Period *

6.1.1.2.2. Start date *

6.1.2. Type of period *

Please fill in the following if "Type of period" = "01 - Employment that is insurance period" or "Type of period" = "02 - Self employment that is insurance period" :
Please fill in the following if "Type of period" = "03 - Employment that is not insurance period" or "Type of period" = "04 - Self employment that is not insurance period" :
Please fill in the following if "Type of period" = "05 - Sickness period that is insurance period or treated as insurance period" or "Type of period" = "06 - Maternity or child raising period that is insurance period or treated as insurance period" :
Please fill in the following if "Type of period" = "07 - Deprivation of Liberty period that is insurance period or treated as insurance period" :
Please fill in the following if "Type of period" = "10 - Other period that is insurance period or treated as insurance period" :

6.1.3.1. Employer or self employment details

6.1.3.1.1. Name *

6.1.3.1.2. Identification numbers

6.1.3.1.2.1. Identification number

6.1.3.1.2.1.1. Number *

6.1.3.1.2.1.2. Type *

6.1.3.1.2.1.Identification number

6.1.3.1.3. Address

6.1.3.1.3.1. Street

6.1.3.1.3.2. Building Name

6.1.3.1.3.3. Town *

6.1.3.1.3.4. Postal Code

6.1.3.1.3.5. Region

6.1.3.1.3.6. Country *

6.1.4.1. Additional details requested?

6.1.4.1.1. Earnings *

6.1.4.1.2. Number of working hours *

6.1.4.1.3. Employment or self employment nature *

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6.1.4.2. Employer or self employment details

6.1.4.2.1. Name *

6.1.4.2.2. Identification numbers

6.1.4.2.2.1. Identification number

6.1.4.2.2.1.1. Number *

6.1.4.2.2.1.2. Type *

6.1.4.2.2.1.Identification number

6.1.4.2.3. Address

6.1.4.2.3.1. Street

6.1.4.2.3.2. Building Name

6.1.4.2.3.3. Town *

6.1.4.2.3.4. Postal Code

6.1.4.2.3.5. Region

6.1.4.2.3.6. Country *

6.1.5.1. Health insurance institution

6.1.5.1.1. Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

6.1.5.1.2.1. Institution ID *

6.1.5.1.2.2. Institution Name *

6.1.5.1.3.1. Institution name *

6.1.5.1.3.2. Institution address *

6.1.5.1.3.2.1. Street

6.1.5.1.3.2.2. Building Name

6.1.5.1.3.2.3. Town *

6.1.5.1.3.2.4. Postal Code

6.1.5.1.3.2.5. Region

6.1.5.1.3.2.6. Country *

6.1.6.1. Prison information

6.1.6.1.1. Name *

6.1.6.1.2. Identification numbers

6.1.6.1.2.1. Identification number

6.1.6.1.2.1.1. Number *

6.1.6.1.2.1.2. Type *

6.1.6.1.2.1.Identification number

6.1.6.1.3. Address

6.1.6.1.3.1. Street

6.1.6.1.3.2. Building Name

6.1.6.1.3.3. Town *

6.1.6.1.3.4. Postal Code

6.1.6.1.3.5. Region

6.1.6.1.3.6. Country *

6.1.7.1. Type

6.1.7.2. Insurance institution details

6.1.7.2.1. Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

6.1.7.2.2.1. Institution ID *

6.1.7.2.2.2. Institution Name *

6.1.7.2.3.1. Institution name *

6.1.7.2.3.2. Institution address *

6.1.7.2.3.2.1. Street

6.1.7.2.3.2.2. Building Name

6.1.7.2.3.2.3. Town *

6.1.7.2.3.2.4. Postal Code

6.1.7.2.3.2.5. Region

6.1.7.2.3.2.6. Country *

6.1.7.3. Activity nature

6.1.Period of insurance, employment or self employment

7. Additional information for the last period of employment or self employment

7.1. Elements for starting date *

7.2. Reason for termination of employment or self employment *

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8. Unemployment benefits periods

8.1. Unemployment benefits period

8.1.1. Period *

Fixed period*
Open period*

8.1.1.1.1. Start date *

8.1.1.1.2. End date *

8.1.1.2.1. Type of Open Period *

8.1.1.2.2. Start date *

8.1.2. Local institution

8.1.2.1. Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

8.1.2.2.1. Institution ID *

8.1.2.2.2. Institution Name *

8.1.2.3.1. Institution name *

8.1.2.3.2. Institution address *

8.1.2.3.2.1. Street

8.1.2.3.2.2. Building Name

8.1.2.3.2.3. Town *

8.1.2.3.2.4. Postal Code

8.1.2.3.2.5. Region

8.1.2.3.2.6. Country *

8.1.Unemployment benefits period

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U001 - Request Insurance Record Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009

U001 - Request Insurance Record
Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009