Certification of the Right to Benefits in Kind

DA002 - Certification of the Right to Benefits in Kind
Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(1) of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Person * [ SC ]

1.1. Person Identification * [ CC ]

1.1.1. Family name(s) *

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1.1.2. Forename(s) *

[ BDT ] {{metaSection.forename.$$error}} {{metaSection.forename.$$warning}}

1.1.3. Date of birth *

[ BDT ] {{metaSection.dateBirth.$$error}} {{metaSection.dateBirth.$$warning}}

1.1.4. Sex *

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1.1.5. Family name(s) at birth

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1.1.6. Forename(s) at birth

[ BDT ] {{metaSection.forenameAtBirth.$$error}} {{metaSection.forenameAtBirth.$$warning}}

1.1.7. PIN of the person in each institution

[ CC ]

1.1.7.1. Personal Identification Number(s) * [ CC ]

1.1.7.1.1. Country *

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1.1.7.1.2. Personal Identification Number (PIN) *

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1.1.7.1.3. Sector

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1.1.7.1.4. Institution

[ CC ]

1.1.7.1.4.1. Institution ID *

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1.1.7.1.4.2. Institution Name *

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1.1.7.1.Personal Identification Number(s)

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

[ CC ]

1.1.8.1. Place of birth

[ CC ]

1.1.8.1.1. Town *

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1.1.8.1.2. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

1.1.8.1.3. Country *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

1.1.8.2. Father's family name at birth

[ BDT ] {{metaSection.fatherFamilyNameAtBirth.$$error}} {{metaSection.fatherFamilyNameAtBirth.$$warning}}

1.1.8.3. Forename of father

[ BDT ] {{metaSection.forenameFather.$$error}} {{metaSection.forenameFather.$$warning}}

1.1.8.4. Mother's family name at birth

[ BDT ] {{metaSection.motherFamilyNameAtBirth.$$error}} {{metaSection.motherFamilyNameAtBirth.$$warning}}

1.1.8.5. Forename of mother

[ BDT ] {{metaSection.forenameMother.$$error}} {{metaSection.forenameMother.$$warning}}

1.2. Additional information on the person [ SC ]

1.2.1. Nationality

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1.2.2. Previous family name(s)

[ BDT ] {{metaSection.previousFamilyName.$$error}} {{metaSection.previousFamilyName.$$warning}}

1.2.3. Previous forename(s)

[ BDT ] {{metaSection.previousForename.$$error}} {{metaSection.previousForename.$$warning}}

2. Addresses of the person [ SC ]

2.1. Address of the person [ SC ]

2.1.1. Address

[ CC ]

2.1.1.1. Street

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2.1.1.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

2.1.1.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

2.1.1.4. Postal Code

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

2.1.1.5. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

2.1.1.6. Country *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

2.1.2. Type of address

[ ENUM ] {{metaSection.typeAddress.$$error}} {{metaSection.typeAddress.$$warning}}

2.1.Address of the person

3. This SED is related to * [ SC ]

3.1. Type Of SED *

[ ENUM ] {{metaSection.typeOfSED.$$error}} {{metaSection.typeOfSED.$$warning}}

3.2. Date *

[ BDT ] {{metaSection.date.$$error}} {{metaSection.date.$$warning}}

3.3. Code

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3.4. Coding System

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3.5. Description

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3.6. Status of the Person

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3.7. Please fill in the following if "Status of the person" = "Other" : [ SC ]

3.7.1. Status of the person (if "Other")

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4. Employer

[ SC ]

4.1. Name *

[ CDT ] {{metaSection.name.$$error}} {{metaSection.name.$$warning}}

4.2. Identification numbers

[ CC ]

4.2.1. Identification number

[ CC ]

4.2.1.1. Number *

[ CDT ] {{metaSection.number.$$error}} {{metaSection.number.$$warning}}

4.2.1.2. Type *

[ ENUM ] {{metaSection.type.$$error}} {{metaSection.type.$$warning}}

4.2.1.Identification number

4.3. Address

[ CC ]

4.3.1. Street

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

4.3.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

4.3.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

4.3.4. Postal Code

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

4.3.5. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

4.3.6. Country *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

5. Information about a person's right to benefits in kind * [ SED ]

5.1. The person has a right to benefits in kind: *

[ ENUM ] {{metaSection.thePersonHasARightBenefitsInKindIndicator.$$error}} {{metaSection.thePersonHasARightBenefitsInKindIndicator.$$warning}}

Please fill in if "The person has a right to benefits in kind" = "Yes" : [ SED ]

Please fill in if "The person has a right to benefits in kind" = "No" : [ SED ]

5.2.1. Right to benefits in kind [ SED ]

5.2.1.1. The person may receive benefits in kind for his accident at work or occupational disease *

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5.2.1.2. Please fill in the following if "The person may receive benefits in kind for his accident at work/occupational disease" = "For a period lasting " : [ CC ]

Fixed period* [ CC ]

Open period* [ CC ]

5.2.1.2.1.1. Start date *

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5.2.1.2.1.2. End date *

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5.2.1.2.2.1. Type of Open Period *

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5.2.1.2.2.2. Start date *

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5.3.1. No right to benefits in kind [ SED ]

5.3.1.1. The person may not receive benefits in kind at our charge

[ ENUM ] {{metaSection.thePersonMayNotReceiveBenefitsInKindAtOurCharge.$$error}} {{metaSection.thePersonMayNotReceiveBenefitsInKindAtOurCharge.$$warning}}

5.3.1.2. Please fill in the following if "The person may not receive benefits in kind at our charge" = "Other" : [ SED ]

5.3.1.2.1. If other, specify

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5.3.1.3. Information about sickness insurance [ SC ]

5.3.1.3.1. Sickness insurance information *

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5.3.1.3.2. Please fill in the following if "Sickness insurance information" = "The person is insured in the following sickness insurance institution" : [ SC ]

5.3.1.3.2.1. Country Code

[ ENUM ] {{metaSection.countryCode.$$error}} {{metaSection.countryCode.$$warning}}

5.3.1.3.2.2. Institution

[ CC ]

5.3.1.3.2.2.1. Institution ID *

[ BDT ] {{metaSection.institutionID.$$error}} {{metaSection.institutionID.$$warning}}

5.3.1.3.2.2.2. Institution Name *

[ CDT ] {{metaSection.institutionName.$$error}} {{metaSection.institutionName.$$warning}}

6. Additional information [ SC ]

6.1. Additional information

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DA002 - Certification of the Right to Benefits in Kind Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(1) of Regulation (EC) No 987/2009

DA002 - Certification of the Right to Benefits in Kind
Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(1) of Regulation (EC) No 987/2009