CA8454 - HM Revenue & Customs

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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? Yes No 3 First name or names If Yes, 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 Yes No If No, are you legally resident in the EU? Yes No 7 Town of birth 16 Do you have a residence outside the UK? Yes No 8 Nationality If Yes, which country or countries? 9 Are you resident in the UK? Full address in that country or countries Yes No If No, go to question 12 10 Full UK address 11 How long have you lived in the UK? 12 In which country do your immediate family members live? <strong>CA8454</strong> Page 2
1 Worker’s details continued 17 Do you spend time in more than one country? 23 In which countries do you carry out your work? Yes No If Yes, please give a brief description of the time spent in each country for example, five days working in the UK, weekends spent not working in France. 24 Do you regularly carry out work in two 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, e mail, 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. Yes No If Yes, give a brief description of your working pattern including what proportion of work you undertake in your country of residence, for example, two days a week working in France, three 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) No 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? Yes No If Yes, 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? Yes go to Part 3 No go to Part 2 <strong>CA8454</strong> Page 3
Page 1: Application for health care cover i
Page 5: Declaration Checklist I declare tha

CA8454 - HM Revenue & Customs

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