Request for additional information

P8000 - Request for additional information
Articles 47(1)(4) of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Local case numbers [ CC ]

1.1. Local Case Number [ CC ]

1.1.1. Country *

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

1.1.2. Case number *

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

1.1.3. Institution [ CC ]

1.1.3.1. Institution ID *

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

1.1.3.2. Institution Name *

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

1.1.Local Case Number

2. Insured person * [ SC ]

2.1. Person identification * [ CC ]

2.1.1. Family name(s) *

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

2.1.2. Forename(s) *

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

2.1.3. Date of birth *

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

2.1.4. Sex *

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

2.1.5. Family name(s) at birth

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

2.1.6. Forename(s) at birth

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

2.1.7. PIN of the person in each institution [ CC ]

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

2.1.7.1.1. Country *

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

2.1.7.1.2. Personal Identification Number (PIN) *

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

2.1.7.1.3. Sector

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

2.1.7.1.4. Institution [ CC ]

2.1.7.1.4.1. Institution ID *

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

2.1.7.1.4.2. Institution Name *

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

2.1.7.1.Personal Identification Number(s)

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

2.1.8.1. Place of birth [ CC ]

2.1.8.1.1. Town *

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

2.1.8.1.2. Region

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

2.1.8.1.3. Country *

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

2.1.8.2. Father's family name at birth

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

2.1.8.3. Forename of father

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

2.1.8.4. Mother's family name at birth

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

2.1.8.5. Forename of mother

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

2.2. Additional information on the person [ SC ]

2.2.1. Additional information on the person [ SC ]

2.2.1.1. Nationality

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

2.2.1.2. Previous family name(s)

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

2.2.1.3. Previous forename(s)

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

2.2.2. Address [ CC ]

2.2.2.1. Street

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

2.2.2.2. Building Name

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

2.2.2.3. Town *

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

2.2.2.4. Postal Code

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

2.2.2.5. Region

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

2.2.2.6. Country *

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

2.2.3. Contact information on the person [ CC ]

2.2.3.1. Telephone Numbers [ CC ]

2.2.3.1.1. Telephone Number [ CC ]

2.2.3.1.1.1. Type

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

2.2.3.1.1.2. Number *

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

2.2.3.1.1.Telephone Number

2.2.3.2. Email Addresses [ CC ]

2.2.3.2.1. Email Address [ CC ]

2.2.3.2.1.1. Email Address

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

2.2.3.2.1.Email Address

3. Other person [ SED ]

3.1. Role of the person

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

3.2. Person identification * [ CC ]

3.2.1. Family name(s) *

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

3.2.2. Forename(s) *

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

3.2.3. Date of birth *

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

3.2.4. Sex *

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

3.2.5. Family name(s) at birth

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

3.2.6. Forename(s) at birth

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

3.2.7. PIN of the person in each institution [ CC ]

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

3.2.7.1.1. Country *

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

3.2.7.1.2. Personal Identification Number (PIN) *

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

3.2.7.1.3. Sector

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

3.2.7.1.4. Institution [ CC ]

3.2.7.1.4.1. Institution ID *

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

3.2.7.1.4.2. Institution Name *

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

3.2.7.1.Personal Identification Number(s)

3.2.8. If PIN not provided for every institution, please provide [ CC ]

3.2.8.1. Place of birth [ CC ]

3.2.8.1.1. Town *

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

3.2.8.1.2. Region

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

3.2.8.1.3. Country *

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

3.2.8.2. Father's family name at birth

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

3.2.8.3. Forename of father

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

3.2.8.4. Mother's family name at birth

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

3.2.8.5. Forename of mother

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

3.3. Additional information on the person [ SED ]

3.3.1. Additional information on the person [ SC ]

3.3.1.1. Nationality

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

3.3.1.2. Previous family name(s)

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

3.3.1.3. Previous forename(s)

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

3.3.2. Address [ CC ]

3.3.2.1. Street

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

3.3.2.2. Building Name

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

3.3.2.3. Town *

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

3.3.2.4. Postal Code

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

3.3.2.5. Region

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

3.3.2.6. Country *

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

3.3.3. Contact information on the person [ CC ]

3.3.3.1. Telephone Numbers [ CC ]

3.3.3.1.1. Telephone Number [ CC ]

3.3.3.1.1.1. Type

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

3.3.3.1.1.2. Number *

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

3.3.3.1.1.Telephone Number

3.3.3.2. Email Addresses [ CC ]

3.3.3.2.1. Email Address [ CC ]

3.3.3.2.1.1. Email Address

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

3.3.3.2.1.Email Address

4. Relationship of the Dependant / Family Member or child to the insured person [ SED ]

4.1. Relationship to the insured person [ SED ]

4.1.1. Relationship to the insured person

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4.2. Please fill in the following if "Relationship to the insured person" = "Other relative" : [ SED ]

4.2.1. Description of other relative

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

5. Reference to the person [ SED ]

5.1. This request is made with reference to the person named in

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6. Request for document(s) [ SED ]

6.1. Please provide us with following documents: *

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6.2. Please fill in the following if "Please provide us with following documents:" = "Other documents" : [ SED ]

6.2.1. Additional information on document(s)

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6.3. Reason for the request

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

7. Request for SED(s) [ SED ]

7.1. Request for SED(s) [ SED ]

7.1.1. Please provide us with following SEDs:

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7.1.2. Please fill in the following if "Please provide us with following SEDs:" = "Other SED(s)" : [ SED ]

7.1.2.1. Other requested SED(s)

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7.1.2.2. Reason for the request

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7.1.Request for SED(s)

8. Request for information [ SED ]

8.1. General information

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8.2. Information on person's benefit(s) [ SED ]

8.2.1. Please inform us if the person is/was claiming; is/was receiving; is/was rejected for the following benefit(s)

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8.2.2. Please fill in the following if "Please inform us if the person is/was claiming; is/was receiving; is/was rejected for the following benefit(s)" = "Other benefits" [ SED ]

8.2.2.1. Other benefit(s)

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8.2.3. Please send us information on [ SED ]

8.2.3.1. Please send us information on

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

8.2.3.2. Please fill in the following if "Please send us information on" = "Other information on benefit(s)" : [ SED ]

8.2.3.2.1. Other information on benefit(s)

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8.2.3.Please send us information on

8.2.Information on person's benefit(s)

8.3. Information on person's activity [ SED ]

8.3.1. Please inform us about the person's activity as

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8.3.2. Please inform

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

8.4. Person's income [ SED ]

8.4.1. Please inform us about the person's income

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

8.4.2. Please state income effective since

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

8.4.Person's income

8.5. Other requested information

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

8.6. Reason for the request

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

9. Request for confirmation of information [ SED ]

9.1. Please confirm the following information

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

9.2. Reason for the request

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

10. Request for person's statement [ SED ]

10.1. Please provide the following statement of the person

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

10.2. Reason for the request

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

11. Additional information [ SC ]

11.1. Additional information

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P8000 - Request for additional information Articles 47(1)(4) of Regulation (EC) No 987/2009

P8000 - Request for additional information
Articles 47(1)(4) of Regulation (EC) No 987/2009