Application for health care cover in the European Economic Area. Why we are sending you this form. What happens next.

Transcription

1 Application for health care cover in the European Economic Area Why we are sending you this form You may be able to get health care cover from the UK for you and your dependants if you are resident in another country in the European Economic Area (EEA), and are liable to pay UK National Insurance contributions. Or your dependants may have the right to health care cover from the UK if they are living in another EEA country and you are liable to pay UK National Insurance contributions. How to apply for health care cover from the UK Please fill in this form in black ink using capital letters. Show dates in the format DD MM YYYY. If you are currently working for a UK employer you must send us a copy of your latest payslip when you return this form. Send the completed form with a copy of your latest payslip to: NIC&EO International Caseworker HMRC BP1301 Benton Park View NEWCASTLE UPON TYNE NE98 1ZZ England If you are a mariner go to and fill in the Mariners Questionnaire by following the link given on that page. Then send this completed application form with a copy of your: mariners discharge book latest payslip completed mariners questionnaire to: Marine NICs HMRC Phase 2, 15th Floor rth Wing Ty Glas Road Llanishen CARDIFF CF14 5FP Wales If you need any help filling in the form and are dialling from the UK, phone us on If you need more space, please use a separate sheet of paper and attach it to this form. We may ask for evidence to confirm information given on this application form. Start date Important: Your right to health cover depends on your liability for UK National Insurance contributions. This means that, depending on your circumstances, the date from which you can get health cover may differ from the one you ask for. What happens next We will send you a document to allow you to register in the country of residence if you are able to get health care cover from the UK. More information If you are resident abroad and normally carry out work in more than 1 EEA country you should ask the social security authorities in the country in which you reside which country you should pay social security contributions to. If you: need health care cover have recently left the UK are not working you should contact the Department for Work and Pensions at the following address: Department for Work and Pensions Overseas Healthcare Team Room MO135 Durham House WASHINGTON NE38 7SF England How we use your information HM Revenue & Customs is a Data Controller under the Data Protection Act We hold information for the purposes specified in our notification to the Information Commissioner, including the assessment and collection of tax and duties, the payment of benefits and the prevention and detection of crime, and may use this information for any of them. We may get information about you from others, or we may give information to them. If we do, it will only be as the law permits to: check the accuracy of information prevent or detect crime protect public funds We may check information we receive about you with what is already in our records. This can include information provided by you, as well as by others, such as other government departments or agencies and overseas tax and customs authorities. We will not give information to anyone outside HM Revenue & Customs unless the law permits us to do so. For more information go to Your rights and obligations Your Charter explains what you can expect from us and what we expect from you. For more information go to CA8454 Page 1 HMRC 05/14

2 1 Worker s details 1 Title for example Mr, Mrs, Miss, Ms, Dr and so on 13 In which country do your children attend school? 2 Last name 14 Have you paid social security contributions in any other EEA Member State? 3 First name or names If, give the name of the country and the social security number Country 4 Gender Number Male Female Country Number 5 Date of birth DD MM YYYY 15 Are you an EEA national? 6 National Insurance number If, are you legally resident in the EU? 7 Town of birth 16 Do you have a residence outside the UK? 8 Nationality If, which country or countries? 9 Are you resident in the UK? Full address in that country or countries If, go to question Full UK address 11 How long have you lived in the UK? 12 In which country do your immediate family members live? CA8454 Page 2

3 1 Worker s details continued 17 Do you spend time in more than 1 country? 23 In which countries do you carry out your work? If, please give a brief description of the time spent in each country. For example, 5 days working in the UK, weekends spent not working in France. 24 Do you regularly carry out work in 2 or more EEA Member States? This includes any kind of work carried out from your home in your country of residence but not if it is less than 5% of your overall activities, such as the occasional use of IT for work purposes, for example 18 Are you internet, , fax or phone employed? self-employed? Give the full name and address of your employer in the box below. Give the full name and address of your place of business in the box below. If, give a brief description of your working pattern including what proportion of work you undertake in your country of residence. For example, 2 days a week working in France, 3 days working in the UK 25 How long do you expect your current employment to last? 19 When did your employment or self-employment start? DD MM YYYY 26 If you are employed as flight crew or cabin crew performing air passenger or freight services, what is your nominated home base? Home base is defined in 20 What is your job title? Annex III to Council Regulations (EEC) 3922/91 as the location nominated by the operator from where the crew member normally starts and ends a duty period 21 Are you a director of the company? If, give a brief description of your duties 27 From what date would you like health care cover to start? DD MM YYYY 22 In what country are you currently paying social security contributions? 28 Are you resident in the UK and only need health care cover for a dependant resident in another EEA Member State? go to Part 3 go to Part 2 CA8454 Page 3

4 2 Worker living abroad 29 What date did you move to your current country 32 Do you intend to return to the UK? of residence? DD MM YYYY If, when do you intend to return? DD MM YYYY 30 In what country were you living before you moved to your current country of residence? If, where do you intend to live in the long term? 31 Give your UK address immediately before leaving the UK 33 Do you maintain a home in the UK? 34 Do you have any dependants living in another EEA Member State needing health care cover? go to Part 3 go to Declaration 3 Dependant s details Please check with the health care institution where you reside to see if an S1 is required for each dependant. Some EEA Member States cover all dependants on one S1 form. If the health care institution confirms you need an S1 for each dependant then please also give the name, address, date of birth, nationality and National Insurance number (if they have one) of each dependant. 35 Full name of dependant 40 Full address 36 Date of birth DD MM YYYY 37 Place of birth 41 Does the dependant carry out any work in their country of residence? 38 Country of residence If, give details 39 UK National Insurance number 42 Social security number in their country of residence CA8454 Page 4

5 Declaration Checklist I declare that the information given on this form is correct. I will tell HMRC about any changes in circumstances. Signature Tick the boxes that apply to you. I have filled in this form and signed the declaration. I have enclosed a copy of my latest payslip. Name I am a mariner and I have enclosed a copy of my: mariners discharge book Date DD MM YYYY completed mariners questionnaire. Phone number I am an agent and confirm that my client has sent you a completed form 64-8 Authorising your agent. I know that you cannot deal with me without this authority. CA8454 Page 5