Certificate of Coverage Information Elements

INFORMATION ELEMENTS COLLECTED WHEN

ISSUING CERTIFICATES OF COVERAGE

COLLECTED UNDER

INFORMATION ELEMENT AGREEMENTS WITH

Name of worker All

Maiden name of worker, if married women Belgium, France, Greece,

Luxembourg, Netherlands

Social Security number of worker All

Date and place of birth All

Citizenship of worker All

Country of permanent residence of worker All

Name and address of U.S. employer or All

self-employment activity

Date and place of hire by U.S. employer All, except Italy

Name and address of foreign employer or All

self-employment activity

If employer is a foreign affiliate of an American All

employer, it is covered by an agreement between

the American parent company and the IRS under

section 3121(l) of the Internal Revenue Code and,

if yes, the effective date of that agreement

Date work in the other country began All

Date work in the other country will end All, except Italy

Address in other country (if known) Sweden, Norway

Name and relationship of family members Netherlands, Norway,

accompanying worker Sweden, Denmark

Maiden name of wife accompanying worker Netherlands

Date of birth of family members Netherlands, Norway,

accompanying worker Denmark

Certification that worker and family members France, Japan

are covered by private health insurance while

in other country