Coordination of Social
Security Systems
A1
Certificate concerning the Social Security
legislation which applies to the holder
EU Regulations 883/04 and 987/09 (*)
INFORMATION FOR THE holder
This certificate concerns the social security legislation which applies to you and confirms that you have
no obligations to pay contributions in another State.
Before you leave the State where you are insured to go to another State to work, make sure you have the
documents which entitle you to receive the necessary benefits in kind (e.g. medical care, treatment in hospital,
and other) in the State where you are working.
- If you are staying temporarily in the State where you are working, ask you health care institution for the
European Health Insurance Card (EHIC). You must show this card to your health care provider if you need benefits
in kind during your stay.
- If you are going to be living in the State where you are working, ask your health care institution for the S1
document and submit it as soon as possible to the competent health care institution of the place you are going to
work.
Provisionally the insurance institution in the State of stay will also provide additional benefits in the event of an
accident at work or an occupational disease.
1. personal details of the holder
1.1 Personal Identification Number Female Male
1.2 Surname
1.3 Forenames
1.4 Surname & forename at birth
1.5 Date of birth 1.6 Place of birth 1.7 Nationality
1.8 Address in the State of residence
1.8.1 Street, N° 1.8.3 Post code
1.8.2 Town 1.8.4 Post code Country code
1.9 Address in the State of stay
1.9.1 Street, N° 1.9.3 Post code
1.9.2 Town 1.9.4 Country code
2. Member state legislation which applies
2.1 Member State
2.2 Starting date 2.3 Ending date
2.4 The certificate applies for the duration of the activity
2.5 The determination is provisional
(*) Regulations (EC) No 883/2004 and 987/2009 articles 11 through 16 and 19, of the European Parliament and
of the Council. A “State” or a “Member State” is any European Union country, plus Iceland, Liechtenstein,
Norway and Switzerland.
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©European Commission
Coordination of Social
Security Systems
A1
Certificate concerning the Social Security
legislation which applies to the holder
3. STATUS confirmation of your position
3.1 Posted employed person 3.2 Employed, working in two or more States
3.3 Posted self-employed person 3.4 Self-employed, in two or more States
3.5 Civil servant 3.6 Auxiliary staff
3.8 Working as an employed person and
3.7 Mariner
as a self-employed person in different countries
3.9 Working as a civil servant in one country 3.10 Exception
and as an employed/self-employed person
in one or more other countries
4. Employer / Self-Employment Details in the State whose legislation applies
4.1.1 Employee 4.1.2 Self-employed activity
4.2 Employer Code
4.3 Name or business name
4.4 Registered address
4.4.1 Street, N° 4.4.2 Country code
4.4.3 Town 4.4.4 Post code
5. Employer / Self-Employment Details IN the other Member State(s)
5.1 Name(s) or business name(s) and code(s) of the firm(s) or ship(s) where you will be employed
5.2 Address(es) or name(s) of ship(s) where you will be (self) employed in the ‘host’ State(s)
5.3 Or no fixed address in State(s) of (self)employment
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Coordination of Social
Security Systems
A1
Certificate concerning the Social Security
legislation which applies to the holder
6. Institution completing THE form
6.1 Name
6.2 Street, N°
6.3 Town
6.4 Post code 6.5 Country code
6.6 Institution ID
6.7 Office fax N°
6.8 Office phone N°
6.9 E-mail
6.10 Date
6.11 Signature
stamp
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