Information on Estimated Costs / Reply to Request for Administrative Check

H131 - Information on Estimated Costs / Reply to 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) *

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

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 *

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

1.1.5. Family name(s) at birth

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

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 *

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

1.1.7.1.2. Personal Identification Number (PIN) *

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

1.1.7.1.3. Sector

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

1.1.7.1.4. Institution [ CC ]

1.1.7.1.4.1. Institution ID *

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

1.1.7.1.4.2. Institution Name *

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

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 *

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

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

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

2. Addresses of the insured person [ SC ]

2.1. Address of the insured person [ SC ]

2.1.1. Type of address

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

2.1.2. Address [ CC ]

2.1.2.1. Street

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

2.1.2.2. Building Name

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

2.1.2.3. Town *

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

2.1.2.4. Postal Code

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

2.1.2.5. Region

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

2.1.2.6. Country *

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

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 *

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

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 *

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

4.2. Dated *

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

4.3. Accident / disease code

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

4.4. Accident / disease coding system

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

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

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

4.6. Status of the person

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

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

4.7.1. Other

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

4.8. Employer * [ CC ]

4.8.1. Name *

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

4.8.2. Identification numbers [ CC ]

4.8.2.1. Identification number [ CC ]

4.8.2.1.1. Number *

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

4.8.2.1.2. Type *

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

4.8.2.1.Identification number

4.8.3. Address [ CC ]

4.8.3.1. Street

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

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

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

4.8.3.6. Country *

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

5. In reply to your request * [ SED ]

for the estimated costs of administrative check [ SED ]

to carry out an administrative check [ SED ]

5.1.1. We inform you that the estimated costs are [ CC ]

5.1.1.1. Amount *

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

5.1.1.2. Currency *

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

5.2.1. The administrative check

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

5.2.2. Reason for not carrying out the administrative check

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

5.2.3. Please fill in the following if "Reason for not carrying out the administrative check" = "Other" : [ SED ]

5.2.3.1. Other reason

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

6. Additional information [ SC ]

6.1. Additional information

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

{{ row.severityMessage }} : {{ row.message }}

H131 - Information on Estimated Costs / Reply to 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

H131 - Information on Estimated Costs / Reply to 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