THE ADMINISTRATIVE COMMISSION See ‘instructions’ on page 3
ON SOCIAL SECURITY
FOR MIGRANT WORKERS E 404 (1)
MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92
A. Request for certificate
To be completed by the institution competent as regards the granting of family benefits.
Applicant for family benefits
n Employed person n Pensioner (scheme for employed persons)
1. n Self-employed person n Pensioner (scheme for self-employed persons)
n Persons other than the aforementioned n Orphan
1.1. Surname (1a)
....................................................................................................................................................................................................................................
1.2. Forenames Previous names (1a) Place of birth (2)
........................................................................... ........................................................................ .........................................................................
1.3. Date of birth Sex Nationality Identification/insurance number ( 3)
................................... .................................. ..................................................................... .........................................................................
4
1.4. Address ( ) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................
2. Person to whom the medical certificate relates
2.1. Surname (1a)
....................................................................................................................................................................................................................................
2.2. Forenames Previous names (1a)
........................................................................... .....................................................................................................................................................
2.3. Place of birth (2) Date of birth Sex Identification/insurance number (3)
..................................... ..................................... ........................................................ .................................................................................
2.4. Address (4)
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
3. Institution competent as regards the granting of family benefits
3.1. Name .......................................................................................................................................................................................................................
3.2. Address (4) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................
3.3. File reference number ..........................................................................................................................................................................................
3.4. Stamp 3.5. Date
.........................................................................
3.6. Signature
.........................................................................
1
E 404
B. Certificate
To be completed by the doctor designated by the liaison body (5) (6) in the country of residence of the person examined and to be sent
to the institution mentioned in box 3.
4.
4.1. (a) The physical or mental faculties of the person examined n have diminished n have not diminished
If they have, indicate percentage of diminution ....................... %
(b) The person examined n is capable of earning his/her living
n is incapable or earning his/her living and continue in the occupational training by studying
owing to physical or mental deficiency
(c) The person examined n is n is not a housewife
If she is, indicate whether n she is n she is not in a fit condition to look after her home
(d) Observations
...............................................................................................................................................................................................................................
...............................................................................................................................................................................................................................
...............................................................................................................................................................................................................................
(e) Description of the condition of the person examined
...............................................................................................................................................................................................................................
...............................................................................................................................................................................................................................
...............................................................................................................................................................................................................................
4.2. Date of commencement of disability or illness (as precise as possible)
....................................................................................................................................................................................................................................
4.3. Probable duration ..................................................................................................................................................................................................
4.4. (a) A further examination n is necessary n is not necessary
(b) If it is, indicate date of the examination ......................................................................................................................................................
5.
5.1. Surname and forenames of the doctor .............................................................................................................................................................
5.2. Address (4) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................
5.3. Date
.........................................................................
5.4. Signature
.........................................................................
2
E 404
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be
left out even if it does not contain any relevant information. It should be completed in the language of the doctor issuing the
certificate.
NOTES
(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 = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SL =
Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH =
Switzerland.
(1a) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames,
surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
(2) In the case of Portuguese districts, state also the parish and the local authority.
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
social security number; to a Norwegian institution, indicate the personal identification number (fødselsnummer); to a Belgian
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI), or
N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a
Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been
insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
(4) Street, number, post code, town, country.
(5) Or the doctor of the fund designated by the liaison body.
(6) In Slovenia, this is the chosen physician.
