Certification of the Right to Benefits in Kind

DA002 - Certification of the Right to Benefits in Kind
Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(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) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

PIN of the person in each institution

Personal Identification Number(s) *

Country *

Personal Identification Number (PIN) *

Sector

Institution

Institution ID *

Institution Name *

Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

Region

Country *

Father's family name at birth

Forename of father

Mother's family name at birth

Forename of mother

Additional information on the person

Nationality

Previous family name(s)

Previous forename(s)

Addresses of the person

Address of the person

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Type of address

Address of the person

This SED is related to *

Type Of SED *

Date *

Code

Coding System

Description

Status of the Person

Please fill in the following if "Status of the person" = "Other" :

Status of the person (if "Other")

Employer

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Information about a person's right to benefits in kind *

The person has a right to benefits in kind: *

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Please fill in if "The person has a right to benefits in kind" = "Yes" :
Please fill in if "The person has a right to benefits in kind" = "No" :

Right to benefits in kind

The person may receive benefits in kind for his accident at work or occupational disease *

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Please fill in the following if "The person may receive benefits in kind for his accident at work/occupational disease" = "For a period lasting " :

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

No right to benefits in kind

The person may not receive benefits in kind at our charge

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Please fill in the following if "The person may not receive benefits in kind at our charge" = "Other" :

If other, specify

Information about sickness insurance

Sickness insurance information *

Please fill in the following if "Sickness insurance information" = "The person is insured in the following sickness insurance institution" :

Country Code

Institution

Institution ID *

Institution Name *

Additional information

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DA002 - Certification of the Right to Benefits in Kind Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(1) of Regulation (EC) No 987/2009

DA002 - Certification of the Right to Benefits in Kind
Article 36 of Regulation (EC) No 883/2004 and Articles 33(1) and (2), 24(1), 25(1) of Regulation (EC) No 987/2009