Request for Periods - Insurance Risk Type: Sickness, Maternity or Paternity

S040 - Request for Periods - Insurance Risk Type: Sickness, Maternity or Paternity
Article 6 of Regulation (EC) No 883/2004; Article 12(1) of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Person *

Person Identification *

Family name(s) *

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Forename(s) *

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Date of birth *

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Sex *

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Family name(s) at birth

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Forename(s) at birth

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PIN of the person in each institution

Personal Identification Number(s) *

Country *

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Personal Identification Number (PIN) *

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Sector

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Institution

Institution ID *

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Institution Name *

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Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

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Region

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Country *

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Father's family name at birth

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Forename of father

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Mother's family name at birth

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Forename of mother

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Additional information on the person

Nationality

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Address of the person

Address *

Street

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Building Name

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Town *

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Postal Code

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Region

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Country *

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Residence in this country since

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Request *

Acting as the competent institution whose legislation makes the acquisition, retention, duration or recovery of the rights to benefits conditional upon the completion of periods, we ask you to confirm relevant periods of insurances, employment, self-employment or residence completed, under your legislation by the period concerned.

Type of benefit concerned *

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Nature of benefit concerned *

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Period concerned *

Fixed period*
Open period*

Start date *

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End date *

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Type of Open Period *

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Start date *

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Additional information

Additional information

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