Reimbursement Request

U020 - Reimbursement Request
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 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 *

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1.1.2. Case number *

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1.1.3. Institution [ CC ]

1.1.3.1. Institution ID *

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1.1.3.2. Institution Name *

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1.1.Local Case Number

2. General information * [ SED ]

2.1. Reimbursement request ID *

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2.2. Number of individual claims *

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2.3. Total amount requested * [ CC ]

2.3.1. Amount *

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2.3.2. Currency *

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2.4. Bank information * [ SC ]

2.4.1. SEPA Bank Details * [ CC ]

2.4.1.1. IBAN *

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2.4.1.2. BIC-SWIFT

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2.4.2. Bank transfer: subject or transaction reference *

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3. Individual claims * [ SED ]

3.1. Individual claim * [ SED ]

3.1.1. Person * [ SC ]

3.1.1.1. Person identification * [ CC ]

3.1.1.1.1. Family name(s) *

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3.1.1.1.2. Forename(s) *

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3.1.1.1.3. Date of birth *

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3.1.1.1.4. Sex *

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3.1.1.1.5. Family name(s) at birth

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3.1.1.1.6. Forename(s) at birth

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

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

3.1.1.1.7.1.1. Country *

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3.1.1.1.7.1.2. Personal Identification Number (PIN) *

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3.1.1.1.7.1.3. Sector

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3.1.1.1.7.1.4. Institution [ CC ]

3.1.1.1.7.1.4.1. Institution ID *

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3.1.1.1.7.1.4.2. Institution Name *

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3.1.1.1.7.1.Personal Identification Number(s)

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

3.1.1.1.8.1. Place of birth [ CC ]

3.1.1.1.8.1.1. Town *

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3.1.1.1.8.1.2. Region

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3.1.1.1.8.1.3. Country *

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3.1.1.1.8.2. Father's family name at birth

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3.1.1.1.8.3. Forename of father

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3.1.1.1.8.4. Mother's family name at birth

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3.1.1.1.8.5. Forename of mother

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3.1.1.2. Additional information on the person [ SC ]

3.1.1.2.1. Nationality

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3.1.2. Reimbursement request ID *

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3.1.3. Sequential number of Individual claim *

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3.1.4. Institution which certified insurance record * [ CC ]

3.1.4.1. Institution ID *

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3.1.4.2. Institution Name *

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3.1.5. Working periods considered * [ SED ]

3.1.5.1. Working period considered * [ CC ]

3.1.5.1.1. Start Date *

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3.1.5.1.2. End Date *

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3.1.5.1.Working period considered

3.1.6. Reimbursement period * [ CC ]

3.1.6.1. Start Date *

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3.1.6.2. End Date *

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3.1.7. Last payment date *

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3.1.8. Requested amount for reimbursement * [ CC ]

3.1.8.1. Amount *

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3.1.8.2. Currency *

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3.1.Individual claim

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U020 - Reimbursement Request Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

U020 - Reimbursement Request
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009