Request Insurance Record

U001 - Request Insurance Record
Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Local case numbers

Local Case Number

Country *

Case number *

Institution

Institution ID *

Institution Name *

Local Case Number

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

Person's current address *

Address details *

Street

Building Name

Town *

Postal Code

Region

Country *

Contact information

Telephone Numbers

Telephone Number

Type

Number *

Telephone Number

Email Addresses

Email Address

Last address in state of former insurance

Street

Building Name

Town *

Postal Code

Region

Country *

Reference period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Periods of insurance, employment or self-employment

Period of insurance, employment or self-employment

Period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Type of period *

Please fill in the following if "Type of period" = "01 - Employment that is insurance period" or "Type of period" = "02 - Self-employment that is insurance period" :
Please fill in the following if "Type of period" = "03 - Employment that is not insurance period" or "Type of period" = "04 - Self-employment that is not insurance period" :
Please fill in the following if "Type of period" = "05 - Sickness period that is insurance period or treated as insurance period" or "Type of period" = "06 - Maternity or child raising period that is insurance period or treated as insurance period" :
Please fill in the following if "Type of period" = "07 - Deprivation of Liberty period that is insurance period or treated as insurance period" :
Please fill in the following if "Type of period" = "99 - Other period that is insurance period or treated as insurance period" :

Employer or self-employment details

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Additional details requested?

Earnings *

Number of working hours *

Employment or self-employment nature *

{{metaSection.employmentOrSelfEmploymentNatureIndicator.$$error}} {{metaSection.employmentOrSelfEmploymentNatureIndicator.$$warning}}

Employer or self-employment details

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Health insurance institution

Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

Institution ID *

Institution Name *

Institution name *

Institution address *

Street

Building Name

Town *

Postal Code

Region

Country *

Prison information

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Type

Insurance institution details

Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

Institution ID *

Institution Name *

Institution name *

Institution address *

Street

Building Name

Town *

Postal Code

Region

Country *

Activity nature

Period of insurance, employment or self-employment

Additional information for the last period of employment or self-employment

Elements for starting date *

Reason for termination of employment or self-employment *

{{metaSection.reasonForTerminationEmploymentOrSelfEmploymentIndicator.$$error}} {{metaSection.reasonForTerminationEmploymentOrSelfEmploymentIndicator.$$warning}}

Unemployment benefits periods

Unemployment benefits period

Period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Local institution

Institution ID is known *

Please fill in the following if "Institution ID is known" = "Yes" :
Please fill in the following if "Institution ID is known" = "No" :

Institution ID *

Institution Name *

Institution name *

Institution address *

Street

Building Name

Town *

Postal Code

Region

Country *

Unemployment benefits period

{{ row.severityMessage }} : {{ row.message }}

U001 - Request Insurance Record Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009

U001 - Request Insurance Record
Article 61 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009