Contestation of Individual Claim - Benefits in Kind (COC)

DA016 - Contestation of Individual Claim - Benefits in Kind (COC)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Global Note COC * [ SED ]

1.1. Global CLA Reference Creditor Liaison Body *

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1.2. Global COC Reference Debtor Liaison Body *

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

1.3. Total Number of Individual Contestations *

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1.4. Total Amount Of Contestations * [ CC ]

1.4.1. Amount *

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1.4.2. Currency *

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1.5. Date Of Submission *

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2. Individual COCs * [ SED ]

2.1. Individual COC * [ SED ]

2.1.1. ID Creditor Institution * [ CC ]

2.1.1.1. Institution ID *

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2.1.1.2. Institution Name *

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2.1.2. ID Debtor Institution * [ CC ]

2.1.2.1. Institution ID *

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2.1.2.2. Institution Name *

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

2.1.3. References * [ SED ]

2.1.3.1. Global CLA Reference Creditor Liaison Body *

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

2.1.3.2. Global COC Reference Debtor Liaison Body *

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2.1.3.3. Individual CLA Number Creditor Liaison Body *

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2.1.3.4. Individual COC Number Debtor Liaison Body *

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2.1.4. Person receiving benefits * [ CC ]

2.1.4.1. Person Information * [ CC ]

2.1.4.1.1. Family name(s) *

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2.1.4.1.2. Forename(s) *

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

2.1.4.1.3. Date of birth *

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

2.1.4.1.4. Sex *

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

2.1.4.2. Family name(s) at birth

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2.1.4.3. Forename(s) at birth

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2.1.4.4. Person Identification Number * [ CC ]

2.1.4.4.1. PIN of the person in Competent Member State *

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2.1.4.4.2. PIN of the person in Member State of Stay or Residence

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2.1.5. Contestation reason * [ SED ]

2.1.5.1. Contestation reason *

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Please fill in the following if "Contestation reason" = "09 - The benefits do not concern an accident at work", "10 - The benefits do not concern an occupational disease", "16 - Cost of benefits have been refunded in full or partially to the insured person" [ SED ]

Please fill in the following if "Contestation reason" = "99 - Other [field Other should be filled in]" [ SED ]

Please fill in the following if "Contestation reason" = "08 - Person died on [date should be field in]" or "17 - Claim introduced after deadline" [ SED ]

Please fill in the following if "Contestation reason" = "13 - Double invoice" [ SED ]

2.1.5.2.1. Details on the contestation reasons *

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2.1.5.3.1. Other

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2.1.5.4.1. Date

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2.1.5.5.1. Information on duplicated invoice [ SED ]

2.1.5.5.1.1. Duplicated Global CLA Creditor Liaison Body

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2.1.5.5.1.2. Duplicated CLA Number Creditor Liaison Body

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2.1.6. Amount of Individual Contestation * [ CC ]

2.1.6.1. Amount *

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2.1.6.2. Currency *

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

2.1.Individual COC

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DA016 - Contestation of Individual Claim - Benefits in Kind (COC) Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

DA016 - Contestation of Individual Claim - Benefits in Kind (COC)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009