DA004 – Request for Reimbursement Rates

Purpose of the SED:

This SED is a request from the competent Member State to the Member State of Stay in which the benefits were provided to determine the reimbursement rates when a person has actually borne the costs of all or part of the benefits in kind received;

For general remarks applicable to all the AWOD SEDs click here.

Data required:

Person Identification Data

Personal data allows the Counterparty to identify the person in the national data base and to provide the reply on the entitlement to benefits in kind in respect to an accident at work or an occupational disease. If the data are not complete or are incorrect the Counterparty, which received DA004, will not be able to reply. It is important to remember about the special characters which can be used in the family name and forenames, which could make a difference for the person identification.

The DA004 should include the Personal Identification Number (PIN). The PIN is defined as a unique personal identification number issued by a state or organization. Whenever it is possible the number entered should be a number given to the person under a National Registration scheme. Where no National Registration Number is available, a sectorial number (i.e. Social security, Health Registration Number) should be entered.

Information about the relation to the accident at work or occupational disease

Please indicate whether the DA004 is related to an accident at work or

an occupational disease. This information might be necessary, particularly when the Member State has two different institutions, one of them in charge of accidents at work and the other one of occupational diseases.

Specification of the request in DA004

Copies of the receipts corresponding to the requested reimbursements should be attached to the SED. List of the attached receipts could be added either as an attachment or in the additional information section of the SED, should it be deemed necessary by the sending Member State.

Information about the benefits in kind provided to the person can also be entered in the SED in the fields for the name of the provider, the town where benefits were provided, costs of the benefits and number of the invoice (given by the healthcare provider or by the institution sending DA004).

The number of attached invoices for which a reimbursement is requested should be provided in the SED.

Additional information

The description of the request in DA004 is a predetermined and does not require or allows for any additional input from the clerk. If necessary, additional information can be provided in “additional information”. The list of the attachment can be provided in additional information.

Mandatory fields (“*”)

DA004 includes some mandatory data, i.e. identification of the person, date of the accident/occupational disease, number of attached invoices.

In order to see the content and explanatory notes of SED DA004 please click here.