Contestation of Individual Claim - Benefits in Kind (COC)

DA016 - Contestation of Individual Claim - Benefits in Kind (COC)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Global Note COC *

Global CLA Reference Creditor Liaison Body *

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Global COC Reference Debtor Liaison Body *

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Total Number of Individual Contestations *

Total Amount Of Contestations *

Amount *

Currency *

Date Of Submission *

Individual COCs *

Individual COC *

ID Creditor Institution *

Institution ID *

Institution Name *

ID Debtor Institution *

Institution ID *

Institution Name *

References *

Global CLA Reference Creditor Liaison Body *

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Global COC Reference Debtor Liaison Body *

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Individual CLA Number Creditor Liaison Body *

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Individual COC Number Debtor Liaison Body *

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Person receiving benefits *

Person Information *

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

Person Identification Number *

PIN of the person in Competent Member State *

PIN of the person in Member State of Stay or Residence

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Contestation reason *

Please fill in the following if "Contestation reason" = "09 - The benefits do not concern an accident at work", "10 - The benefits do not concern an occupational disease", "16 - Cost of benefits have been refunded in full or partially to the insured person"
Please fill in the following if "Contestation reason" = "99 - Other [field Other should be filled in]"
Please fill in the following if "Contestation reason" = "08 - Person died on [date should be field in]" or "17 - Claim introduced after deadline"
Please fill in the following if "Contestation reason" = "13 - Double invoice"

Details on the contestation reasons *

Other

Date

Information on duplicated invoice

Duplicated Global CLA Creditor Liaison Body

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Duplicated CLA Number Creditor Liaison Body

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Amount of Individual Contestation *

Amount *

Currency *

Individual COC

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DA016 - Contestation of Individual Claim - Benefits in Kind (COC) Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

DA016 - Contestation of Individual Claim - Benefits in Kind (COC)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009