Insurance Record - Cross border Worker

U017 - Insurance Record - Cross border Worker
Articles 61, 65 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

Reference period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Entitled to benefits *

Entitled? *

Please fill in the following if "Entitled?" = "Yes" :
Please fill in the following if "Entitled?" = "No" :

Article number

Entitlement period

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Reason

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" = "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 *

Requested additional details

Earnings and or hours

Period *

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Gross earnings

Amount *

Currency *

Number of working hours

Earnings and or hours

Employment or self-employment nature

Employer or Self-employment details

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Type

Please fill in the following if "Type" = "02 - Compensation for vacation not taken" :
Please fill in the following if "Type" = "99 - Other period treated as a period of insurance" :

Vacation not taken

Amount *

Currency *

Type of 'Other period treated as a period of insurance'

Period of insurance, employment or self-employment

Elements concerning the last employment or self-employment important for starting date of benefits

Type of amounts

Type of amount

Payment *

Amount *

Currency *

Please fill in the following if "Type of amount" = "01 - Wages for period after termination of employment or self-employment" :
Please fill in the following if "Type of amount" = "02 - Compensation for vacation not taken (Annual leave)" :

Received for period until

Number of days

Type of amounts

Waived rights

Reason

Other benefit(s)

Reason for termination of the last employment or self-employment

Termination reason of employment

Please fill in the following if "Termination reason of employment" = "99 - Other" :

Other termination

Termination reason of self-employment

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

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U017 - Insurance Record - Cross border Worker Articles 61, 65 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009

U017 - Insurance Record - Cross border Worker
Articles 61, 65 of Regulation (EC) No 883/2004; Article 54(1) of Regulation (EC) No 987/2009