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Document 01998D0441-20060401

Consolidated text: Decision No 166 of 2 October 1997 on the amending of forms E 106 and E 109 (Text with EEA relevance) (98/441/EC)

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1998D0441 — EN — 01.04.2006 — 001.001

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DECISION No 166

of 2 October 1997

on the amending of forms E 106 and E 109

(Text with EEA relevance)

(98/441/EC)

(OJ L 195, 11.7.1998, p.25)

Amended by:

 

 

Official Journal

  No

page

date

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DECISION No 202 of 17 March 2005

  L 77

1

15.3.2006



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DECISION No 166

of 2 October 1997

on the amending of forms E 106 and E 109

(Text with EEA relevance)

(98/441/EC)

THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS,

Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community, under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent Regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the application of the Regulations,

Having regard to Decision No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127),

Whereas Council Regulation (EC) No 3095/95 of 22 December 1995 has amended Article 17(2) and Article 30(1) of Regulation (EEC) No 574/72 by limiting to one year the peirod of validity of forms E 106 and E 109 issued by German, Italian or Portuguese institutions;

Whereas forms E 106 and E 109 must therefore be adapted;

Whereas the Agreement of the European Economic Area of 2 May 1992, as amended by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area;

Whereas by Decision of the EEA Joint Committee the model forms necessary for the application of Regulation (EEC) No 1408/71 and Regulation (EEC) No 574/72 will be adapted and implemented within the European Economic Area;

Whereas for practical reasons identical forms should be used within the Community and within the European Economic Area;

Whereas the language in which forms should be issued is the subject of Recommendation No 15 of the Administrative Commission,

HAS DECIDED AS FOLLOWS:



1.

The model forms E 106 and E 109 reproduced in Decision No 153 of 7 October 1993 shall be replaced by the models appended hereto.

2.

The competent authorities of the Member States shall make the appended forms available to the persons concerned (rightful claimants, institutions, employers, etc.). However, the introduction of new model forms does not affect the validity of existing models.

3.

Each form shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all persons or bodies to whom a form is addressed (rightful claimants, institutions, employers, etc.) to receive the form printed in their own language.

4.

This Decision shall be published in the Official Journal of the European Communities and shall be applicable from 1 January 1998.

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ADMINISTRATIVE COMMISSIONON SOCIAL SECURITYFOR MIGRANT WORKERSE 106(1)CERTIFICATE OF ENTITLEMENT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND FOR PERSONS RESIDING IN ACOUNTRY OTHER THAN THE COMPETENT COUNTRYEmployed and self-employed persons and members of their families residing with them; members of the family of unemployed personsRegulation (EEC) No 1408/71: Article 19(1)(a) ; Article 19(2) and Article 25(3)(i)Regulation (EEC) No 574/72: Article 17(1) and (4) and Article 27 (first sentence)The competent institution should complete Part A of the form and send two copies to the insured person, or send them — where necessary throughthe liaison body — to the institution in the place of residence if the form is drawn up at that institution's request. As soon as it has received the twocopies, the latter institution should complete Part B and return one copy to the competent institution.Please complete this form in block letters, writing on the dotted lines only. It consists of 4 pages, none of which may be left out.A. Notification of entitlement1. Institution of the place of residence (2)1.1 Name: ………………………………………………………………………………………………………………………………………………….1.2 Identification number of the institution: …………………………………………………………………………………………1.3 Address:………………………………………………………………………………………………………………………………………………….………………………………1.4 Reference: your E 107 form of ……………………………………………………………………………………………………………………….2. The insured person2.1 Surname(s) (3):……………………………………………………………………………………………………………………………………………………………..2.2 Forename(s) (4):……………………………………………………………………………Date of birth:…………………………………………………………………………….2.3 Previous name(s): ………………………………………………………………………………………………………………………………………2.4 Address in the country of residence:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….2.5 Personal identification number:……………………………………………………………………………………………………………………………………………………………..2.6 The insured personis a employed person2.7 The insured personis a self-employed person2.8 The insured personis a frontier worker (employed)2.9 The insured personis a frontier worker (self employed)2.10 The insured personis an unemployed worker3. Member of the family (5)3.1 Surname(s) (3):……………………………………………………………………………………………………………………………………………………………..3.2 Forename(s) (4):……………………………………………………………………………Date of birth:…………………………………………………………………………….3.3 Previous name(s): ……………………………………………………………………………………………………………………………………….3.4 Address in the country of residence: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..3.5 Personal identification number: …………………………………………………………………………………………………………………4.1The abovementioned insured person and the members of his family (6) residing with him4.2The members of the family (6) of the above unemployed person5. are entitled to sickness and maternity insurance benefits in kindas from …………………………………………………………………………………………………………………………………………………

E 1066. The persons concerned will retain their entitlement6.1until this certificate is cancelled6.2for a period of one year from the date specified in point 5 (7)6.3until ……………………………………………………………………………………………………………. inclusive (8)7. Competent institution for sickness and maternity insurance7.1 Name: …………………………………………………………………………………………………………………………………………………..7.2 Identification number of the institution: …………………………………………………………………………………………7.3 Address:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....…………………………………………………………………………………………………………………………………………………………....7.4 Stamp7.5 Date: ………………………………………………………...7.6 Signature:………………………………………………………………..B. Notification of registration (9)8.8.1The insured person named in box 2 and the members of his family8.2The members named in box 3 of the family of the unemployed person8.3were registered with us on …………………………………………………………………………………………………………………………8.4cannot be registered with us because …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..9.9.1Surname(s) (3)Forename(s) (4)Previous name(s)Date of birthPersonal identification number9.2…………………………………………………..……………………………………….…………………………………………………….9.3…………………………………………………..……………………………………….…………………………………………………….9.4…………………………………………………..……………………………………….…………………………………………………….9.5…………………………………………………..……………………………………….…………………………………………………….9.6…………………………………………………..……………………………………….…………………………………………………….9.7…………………………………………………..……………………………………….…………………………………………………….9.8…………………………………………………..……………………………………….…………………………………………………….9.9…………………………………………………..……………………………………….…………………………………………………….10. Institution of the place of residence10.1 Name: ………………………………………………………………………………………………………………………………………………….10.2 Identification number of the institution: ………………………………………………………………………………………10.3 Address:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....…………………………………………………………………………………………………………………………………………………………....10.4 Stamp10.5 Date: ………………………………………………………..10.6 Signature:……………………………………………………………….

E 106Information for the insured person(a) This form entitles you to receive sickness and maternity insurance benefits in kind for yourself and the members of your family. If you areunemployed, this form is not intended for you; it is intended solely for members of your family who reside in a Member State other than theone where you are insured.(b) The two copies of the form which are in your possession must be submitted as soon as possible to the sickness and maternity insuranceinstitution in your place of residence. If you are unemployed, the form must be submitted by the members of your family to the sickness andmaternity insurance institution in their place of residence.(c) The sickness and maternity insurance institutions are:inBelgium, the ‘mutualité’ (local sickness insurance fund) chosenin theCzech Republic, ‘Zdravotní pojišťovna’, the health insurance fund in the place of residenceinDenmark, the municipal authority in the place of residenceinGermany, the ‘Krankenkasse’ (sickness insurance fund) chosen by the person concernedinEstonia, ‘Eesti Haigekassa’ (Estonian Health Insurance Fund)inGreece, normally the regional or local branch of the Social Insurance Institute (IKA). The branch office should issue the person concernedwith a ‘health book’ without which no benefits in kind can be providedinSpain, the ‘Dirección Provincial del Instituto Nacional de la Seguridad Social’ (Provincial Directorate of the National Social SecurityInstitution) in the place of residence. If you require benefits you may apply to the medical and hospital service of the Spanish social securityhealth system. You must submit the form together with a photocopyinFrance, the ‘Caisse primaire d'assurance-maladie’ (local sickness insurance fund)inIreland, the local health office of the Health Service ExecutiveinItaly, normally the ‘Unità sanitaria locale’ (ASL, the local health administration unit) responsible for the area concerned. For mariners andfor civilian aircrews, the ‘Ministero della Sanità — Ufficio di sanità marittima o aerea’ (Ministry of Health, area health office for the merchantnavy or civil aviation)inCyprus, ‘Υπουργείο Υγείας’ (Ministry of Health,1448 Lefkosia), Upon application, the person concerned will be provided with a Cyprusmedical card, without which no benefits in kind can be provided at the Government Medical institutionsinLatvia, ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsary Insurance State Agency)inLithuania, ‘the Teritoriné ligoniu kasa’ (Territorial Patient Fund)', sickness and maternity institutionsinLuxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers)inHungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (local health insurance office)inMalta, the Entitlement Unit, Ministry of Health, 23, John Street, Vallettain theNetherlands, any sickness fund competent for the place of residenceinAustria, the ‘Gebietskrankenkasse’ (Regional Fund for Sickness Insurance) competent for the place of residenceinPoland, the regional branch of the Narodowy Funsdusz Zdrowia (National Health Fund) competent for the place of residenceinPortugal, formetropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (District Solidarity and Social SecurityCentre) in the place of residence; forMadeira: the ‘Centro de Segurança Social da Madeira’ (Social Security Centre of Madeira) in Funchal;for theAzores: the ‘Centro de Prestações Pecuniárias’ (Centre for Cash Benefits) in the place of residenceinSlovenia, the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institute of Slovenia)inSlovakia, the ‘zdravotná poisťovňa’ (health insurance company) of the insured person's choiceinFinland, the local office of the ‘Kansaneläkelaitos’ (Social Insurance Institution)inSweden, 'Försäkringskassan (Local Social Insurance Office) in the place of residencein theUnited Kingdom, the Department for Work and Pensions, the Pension Service, International Pension Centre, Tyneview Park,Newcastle-upon-Tyne, or for Northern Ireland the Department for Social Development, Overseas Benefits Branch, Block 2, Castle Buildings,Belfast, as appropriateinIceland, ‘Tryggingastofnun rikisins’ (The State Social Security Institute), ReykjavikinLiechtenstein, the ‘Amt für Volkswirtschaft’ (Office of National Economy), VaduzinNorway, the ‘lokale trygdekontor’ (the local Insurance office) in the place of residenceinSwitzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint Institution underthe Federal Sickness Insurance Act), Solothurn.(d) This form is valid from the date indicated in item 5 and for the period indicated in box 6 by the square marked with a cross.(e) You or the members of your family must inform the insurance institution to which the form has been submitted of any change of circumstanceswhich might affect the right to benefits in kind, such as termination or change of employment, change of your place of residence or stay or ofthat of a member of your family.

E 106NOTES(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Complete only if the form is drawn up at the request of the institution in the place of residence.(3) State surnames in civil status order.(4) State the forenames in civil status order.(5) Complete only if the form relates to members of the family of an unemployed person. Mention one member of the family only forregistration, since the legislation of the country of residence determines which members of the family are entitled to benefit.(6) The legislation of the country of residence determines which members of the family are entitled to benefit.(7) If the form is issued by a German, French, Italian or Portuguese institution.(8) If the form is issued by a Greek, Hungarian or United Kingdom institution for employed persons or self-employed persons.(9) If this form is issued in renewal of a certificate previously provided, part B need not be completed.

ADMINISTRATIVE COMMISSIONON SOCIAL SECURITY FORMIGRANT WORKERSE 109(1)CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF AN INSURED PERSON'S FAMILY AND THE UPDATING OF LISTSRegulation (EEC) No 1408/71: Article 19(2)Regulation (EEC) No 574/74: Article 17(1), (2), (3) and (4) and Article 94(4)The competent institution should complete part A of the form and issue two copies to the insured person or send them, where necessary throughthe liaison body, to the institution in the place of residence if the form has been drawn up at that institution's request. Where the members of theinsured person's family are resident in the United Kingdom, the competent institution should send the two copies to the Department for Work andPensions, Pension Service, International Pension Centre, Tyneview Park, Newcastle-upon-Tyne. On receipt of the two copies, the institution of theplace of residence should complete part B and return one copy to the competent institution. Where the members of the family are resident indifferent countries, a separate certificate should be drawn up for each of these countries.Please complete the form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out.A. Notification of entitlement1. Institution in the place of residence (2)1.1 Name: …………………………………………………………………………………………………………………………………………………..1.2 Identification number of the institution: ………………………………………………………………………………………………………………1.3 Address: ……………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………….1.4. Reference: your E 107 form of ………………………………………………………………………………………………………………………2. The insured person2.1 Surname(s) (3):……………………………………………………………………………………………………………………………………………………………..2.2Forename(s) (4):……………………………………………………………………………Date of birth:……………………………………………………………………………2.3 Previous name(s): ………………………………………………………………………………………………………………………………………2.4 Address: ………………………………………………………………………………………………………………………………………...……..…………………………………………………………………………………………………………………………………………………………….2.5 Personal identification number:…………………………………………………………………………………………………………………………………………………………….2.6 The insured personisa self-employed worker3. Member of the family3.1 Surname(s) (3):……………………………………………………………………………………………………………………………………………………………..3.2Forename(s) (4):……………………………………………………………………………Date of birth:…………………………………………………………………………….3.3 Previous name(s): ………………………………………………………………………………………………………………………………………3.4 Address: ………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………..3.5 Personal identification number: ………………………………………………………………………………………………………………………..4. The members of the family of the abovementioned insured person are entitled to sickness and maternity insurance benefits in kind unlessthey are already entitled to such benefits under the legislation of the country in which they reside (5)they are pursuing a professional activity or trade (5)5. This entitlement begins on ……………………………………………………………………………………………………………..…………….

E 1096. and continues6.1until this certificate is cancelled6.2for one year from the date specified in point 5 (6)6.3until the date on which the seasonal work is due to end, i.e.6.4until (7) ……………………………………………………………………………………………………………………………….. inclusive.7Please return the European Health Insurance Card of the in section 3 mentioned member of the family with number ………………………………….. and valid till ………………………..8. Competent institution8.1 Name: ………………………………………………………………………………………………………………………………………………….............8.2 Identification number of the institution: ……………………………………………………………………………………………………………8.3 Address: ………….…………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………...8.4 Stamp8.5 Date: ……………………………………………………….8.6 Signature……………………………………………………………….B.Notification of registration (8)9.(9)The following family members have not been registeredSurnames (3)Forenames (4)Date of birthPersonal identification number9.1………………………………………..……………………………….…………………………..…………………………………………9.2………………………………………..……………………………….…………………………..…………………………………………9.3………………………………………..……………………………….…………………………..…………………………………………9.4………………………………………...………………………………………………………………………………………………………9.5………………………………………...…………………………………………………………….…………………………………………9.6………………………………………...………………………………….……………………………………………………………………9.7………………………………………..………………………………………………………………………………………………………9.8………………………………………..………………………………………………………………………………………………………9.9………………………………………..………………………………………………………………………………………………………9.10………………………………………..………………………………………………………………………………………………………BecauseThey are not entitled to benefitsThey are already entitled to benefits in kindother reasons10.(9)The following members of the family of the insured person named in box 2 have been registered:Surnames (3)Forenames (4)Date of birthPersonal identification number10.1………………………………………...………………………………………………………………………………………………………..10.2………………………………………...…………………………………………………………….………………………………………….10.3………………………………………...……………………………………………………………………………………………………….10.4………………………………………...…………………………………………………………….………………………………………….10.5………………………………………...……………………………………………………………………………………………………….10.6………………………………………..………………………………….…………………………………………………………………….10.7………………………………………..………………………………….…………………………………………………………………….10.8………………………………………..………………………………….…………………………………………………………………….10.9………………………………………..………………………………….…………………………………………………………………….10.10 The cost of these benefits is payable by you. The date from which the lump sum referred to in Article 94 of Regulation (EEC) No 574/72 should be calculated is ……………………………………………………………………………………………………………………………………….

E 10911 European Health Insurance Card11.1Please find attached the European Health Insurance Card with number …….. as requested in section 711.2Please indicate the measures to be applied concerning the European Health Insurance card issued to the in section 3 mentioned member of the family with number …………………………….. and valid till ……………………………………….12. Institution in the place of residence12.1 Name: …………………………………………………………………………………………………………………….…………………………….12.2 Identification number of the institution:12.3 Address: …………………………………………………………………………………………………………………….………………………….………………………………………………………………………………………………………………………………………….………………….12.4 Stamp10.5 Date …………………………………………………………10.6 Signature…………………………………………………………………Instructions for the insured person(a) This form enables the members of your family to receive benefits in kind in case of sickness or maternity in the country where they areresident and under the legislation of that country, unless they are already entitled to such benefits under that legislation.(b) As soon as you have received the two copies of the form, you should send them to the members of your family, who should submit themimmediately to the sickness and maternity insurance institution in their place of residence, i.e.:inBelgium, the ‘mutualité’ (local sickness insurance fund) of your choice;in theCzech Republic, ‘Zdravotní pojišťovna’ (the health insurance fund) of your place of residence;inDenmark, the municipal authority of the place of residence;inGermany, the ‘Krankenkasse’ (sickness insurance fund) of your choice;inEstonia, the ‘Haigekassa Eesti’ (Estonian Health Insurance Fund);inGreece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a ‘healthbook’ without which no benefits in kind can be provided;inSpain, the ‘Dirección Provincial’ del Instituto Nacional de la Seguridad Social (Provincial Directorate of the National Social SecurityInstitution)inFrance, the ‘Caisse primaire d'assurance-maladie’ (local sickness insurance fund).inIreland,the local health office of the Health Service Executive; inItaly, normally the ‘Unità sanitaria’ locale (local health administration unit) responsible for the area concerned;inCyprus, the ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia), the sickness and maternity institutions; Upon application, the personconcerned will be provided with a Cyprus Medical Card, without which no benefits in kind can be provided at the Government MedicalInstitutions;inLatvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency)inLithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund), sickness and maternity institutionsinLuxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);inHungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);inMalta, the Entitlement Unit, Ministry of Health, 23 John Street, Valletta;in theNetherlands, any sickness fund competent for the place of residence;inAustria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence;in Poland, the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund) competent for the place of residence;inPortugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (Regional Centre for Solidarity and SocialSecurity) of the place of residence; for Madera: the Centro de Segurança Social da Madeira (Madeira Social Security Centre), Funchal; forthe Azores: the Centro de Prestações Pecuniárias (Centre for Cash Benefits) of the place of residence;inSlovenia, to the regional unit of the the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institution of Slovenia)competent for the place of residence;inSlovakia, the ‘zdravotná poisťovňa’ (health insurance icompany) of the insured person's choice;inFinland, the local office of the ‘Kansaneläkelaitos’ (Social Insurance Institution);inSweden, ‘Försäkringskassan’ (Local Social Insurance Office) at the place of residence;in theUnited Kingdom, the Department for Work and Pensions, Pension Service, International Pension Centre, Tyneview Park, Newcastleupon Tyne or, for Northern Ireland, the Department for Social Development, Overseas Benefits Branch, Block 2, Castle Buildings, Belfast;inIceland, the ‘Tryggingastofnun rikisins’ (the State Social Security Institute), Reykjavik;inLiechtenstein, the ‘Amt für Volkswirtschaft’ (Office of National Economy), Vaduz;inNorway, the ‘lokale trygdekontor’ (local Insurance office) at the place of residence;inSwitzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint institution underthe Federal Sickness Insurance Act), Solothurn.(c) This form is valid from the date indicated in section 5 and for the period indicated in section 6 by the box marked with a cross.(d) Both you and the members of your family are required to inform the institution of any change of circumstances which might affect the right tobenefits in kind, such as termination or change of employment, or change in your or a family member's place of residence or stay.

E 109NOTES(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal;SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK= United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;CH = Switzerland.(2) Complete only if the form is being drawn up at the request of the institution of the place of residence.(3) Give the full surname in the order of civil status.(4) Give the forenames in the order of civil status.(5) Put a cross in the box if the form is addressed to an Irish or United Kingdom institution.(6) If the form is issued by a German, French, Italian or Portuguese institution.(7) If the form is issued by a Greek, Hungarian or United Kingdom institution for employed or self-employed persons.(8) If this certificate is issued in renewal of a previously issued certificate which has expired, the institution of the place of residence need notcomplete part B.(9) Complete section 9 or 10 as applicable and put a cross in the corresponding box.

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