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: 0.15.2 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) *

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1.1.3. Date of birth *

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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

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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

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1.1.8.1.3. Country *

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1.1.8.2. Father's family name at birth

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1.1.8.3. Forename of father

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1.1.8.4. Mother's family name at birth

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1.1.8.5. Forename of mother

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1.2. Additional information on the person [ SC ]

1.2.1. Nationality

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2. Addresses of the insured person [ SC ]

2.1. Address of the insured person [ SC ]

2.1.1. Type of address

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2.1.2. Address [ CC ]

2.1.2.1. Street

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2.1.2.2. Building Name

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2.1.2.3. Town *

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2.1.2.4. Postal Code

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2.1.2.5. Region

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2.1.2.6. Country *

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2.1.Address of the insured person

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

3.1. Person Status *

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

4.1. This SED is related to *

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4.2. Dated *

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4.3. Accident / disease code

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4.4. Accident / disease coding system

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

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4.6. Status of the person

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

4.7.1. Other

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4.8. Employer * [ CC ]

4.8.1. Name *

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4.8.2. Identification numbers [ CC ]

4.8.2.1. Identification number [ CC ]

4.8.2.1.1. Number *

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4.8.2.1.2. Type *

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4.8.2.1.Identification number

4.8.3. Address [ CC ]

4.8.3.1. Street

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4.8.3.2. Building Name

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

4.8.3.3. Town *

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

4.8.3.4. Postal Code

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

4.8.3.5. Region

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4.8.3.6. Country *

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5. Period concerned * [ SED ]

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

5.1.1. Period * [ CC ]

5.1.1.1. Start Date *

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5.1.1.2. End Date *

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6. Nature of request * [ SED ]

6.1. We ask you to *

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

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8. Attachments [ SC ]

8.1. Predefined Documents

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8.2. Other Documents Attached [ SC ]

8.2.1. Other Document [ SC ]

8.2.1.1. Document

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8.2.1.Other Document

9. Additional information [ SC ]

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