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GKV-Spitzenverband
Deutsche Verbindungsstelle
Krankenversicherung - Ausland
Postfach 20 04 64
53134 Bonn
GERMANY
Self-employed activity in several Member States1
Dear Sir or Madam,
I am self-employed and normally carry out my activity in several Member States1. As according to article 13(2)
of Regulation (EC) 883/04 for the Coordination of Social Security Systems the legislation of only one State applies
to me and since my place of residence (centre of vital interests) is in Germany, I am asking you to determine the
legislation on Social Security applicable to me.
1. My personal and contact details
Last name ........................................................ First name .........................................................................
00.00.0000
Name at birth .................................................. Date of birth ......................................................................
Sex
male
female
Place of birth ....................................................................
German pension
insurance number ............................................ Nationality ......................................................................
Address in Germany (centre of vital interests)
Street and number ........................................................................................................................................
Postcode ......................................... Town/city ........................................................................................
Phone number2 .................................... E-Mail2 .........................................................................................
2. Details on social security in Germany
I have health insurance with the following German statutory health insurance fund:
Name and address ................................................................................................................................
...............................................................................................................................................................
I have private health insurance.
I currently have health insurance with
a foreign institution or company.
(Please only fill in the following part if you are not insured with a German statutory health insurance fund and if you are a member
of a professional pension scheme for the liberal professions (“berufsständische Versorgungseinrichtung”)
Name and address of the competent institution of the professional pension scheme (“Versorgungswerk“)
.......................................................................................................................................................................
................................................................................................ Membership no.
........................................
1 The term “Member State“ refers to EU States, Iceland, Liechtenstein, Norway and Switzerland.
2 Voluntary specification, for further enquiries.
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3. Details regarding my self-employed activity
3.1 General information
A certificate E101 or A1 has been issued to me already. It is valid until .................................................
No certificate E101 or A1 has been issued to me yet. I need a certificate A1 beginning on ........................
I normally carry out my self-employed activity in Germany and in one other Member State.1
Please go to points 3.2 and 3.3 now.
I normally carry out my self-employed activity in Germany and in at least two other Member States.1
Please go to points 3.2 and 3.4 now.
I normally carry out my self-employed activity exclusively outside of Germany.
Please go to point 3.4 now.
3.2 Details regarding my self-employed activity in Germany
My self-employed activity is registered in Germany as follows:
Name/company name ....................................................................................................................................
Street and number .........................................................................................................................................
Postcode .......................................... Town/city .........................................................................................
Legal status of the company ..........................................................................................................................
Tax number ..................................... Company number (if available) ..........................................................
I do not have a place of business in Germany, but I normally also carry out my self-employed activity here.
3.2.1 Working time
Within the past 12 months I have usually been working in Germany on
........... days a month.
........... days a quarter.
I assume that
I am also going to work in Germany to the same extent in the next 12 months.
the extent of work carried out in Germany is going to change as follows in the next 12 months
Number of working days per month ......................
Number of working days per quarter ....................
Reason for the change: ...........................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
1 The term “Member State“ refers to EU States, Iceland, Liechtenstein, Norway and Switzerland.
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I have been pursuing my self-employed activity in Germany
since ................................ and until further notice.
on a temporary basis from ................................ to ................................ .
3.2.2 Place(s) of activity
I do not have a permanent place of activity in Germany (e.g. due to frequent changes of location).
I am working at the following permanent place of activity in Germany:
Name .....................................................................................................................................................
Street and number ..................................................................................................................................
Postcode and town/city ..........................................................................................................................
3.2.3 Part of the self-employed activity carried out in Germany
Measured in terms of working time, turnover, income and the number of services to be rendered,
I will presumably pursue a part of
more than 25% of my self-employed activity in Germany
less than 25% of my self-employed activity in Germany
in the next 12 months.
3.3 Details on the self-employed activity in Germany and in one other Member State1
I normally pursue my self-employed activity in Germany as well as in .......................................... (other
Member State).1
My self-employed activity is registered in the other Member State1 as follows
Name/company name ....................................................................................................................................
Street and number .........................................................................................................................................
Postcode .......................................... Town/city .........................................................................................
Legal status of the company ............ Code (if available) .............................................................................
I do not have a place of business in the other Member State1, but normally also carry out my selfemployed activity there.
3.3.1 Working time
Within the past 12 months I have usually been working in the other Member State1 on
....... days a month.
....... days a quarter.
I assume that
I will also be working there to the same extent in the next 12 months.
the extent of work carried out there is going to change as follows in the next 12 months:
Number of working days per month ......................
Number of working days per quarter ......................
Reason for the change: ..........................................................................................................................
.................................................................................................................................................................
1 The term “Member State“ refers to EU States, Iceland, Liechtenstein, Norway and Switzerland.
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I have been pursuing my self-employed activity in the other Member State1
since ................................ and until further notice.
on a temporary basis from ................................ to ................................ .
3.3.2 Place(s) of activity
I do not have a permanent place of activity in the other Member State (e.g. due to frequent changes of location).
I am working at the following permanent place of activity in the other Member State1:
Name .....................................................................................................................................................
Street and number .................................................................................................................................
Postcode and town/city .........................................................................................................................
3.4 Details on the self-employed activity outside of Germany in two or more Member States1
3.4.1 Working time
I normally pursue my self-employed activity outside of Germany in at least two Member States1.
Experience shows that working time is distributed as follows:
State
Days per month Days per quarter
Duration of activity
from ......................... to ........................
........................................
................
..................
from ......................... until further notice
from ......................... to ........................
........................................
................
..................
........................................
................
..................
........................................
................
..................
from ......................... until further notice
from ......................... to ........................
from ......................... until further notice
from ......................... to ........................
from ......................... until further notice
for further States please see attachment
I assume that
I will also be working there to the same extent in the next 12 months.
the extent of work carried out there is going to change as follows in the next 12 months:
Number of working days per month ......................
Number of working days per quarter ......................
Reason for the change: ..........................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
3.4.2 Place(s) of activity
I am not registered as a self-employed person in the following States, but I also normally carry out an
activity there at changing locations:
................................................................................................................................................................
................................................................................................................................................................
For further States please see attachment
1 The term “Member State“ refers to EU States, Iceland, Liechtenstein, Norway and Switzerland.
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In the following States I am working at the following permanent places of activity:
State ......................................................................................................................................................
Name ....................................................................................................................................................
Street and number .................................................................................................................................
Postcode and town/city .........................................................................................................................
Legal status ................................................... Code ...........................................................................
State ......................................................................................................................................................
Name ....................................................................................................................................................
Street and number .................................................................................................................................
Postcode and town/city .........................................................................................................................
Legal status ................................................... Code ...........................................................................
State ......................................................................................................................................................
Name ....................................................................................................................................................
Street and number .................................................................................................................................
Postcode and town/city .........................................................................................................................
Legal status ................................................... Code ...........................................................................
For further States please see attachment
- Please only fill in the following point, if the part of the activity you are pursuing in Germany is less than 25% 3.5 Centre of the self-employed activity
In the next 12 months the extent of my self-employed activity will presumably be distributed among the
following States as follows:
Germany
Turnover .......................................................................................................................................................
Income ..........................................................................................................................................................
Number of services .......................................................................................................................................
State ................................................................
Turnover .......................................................................................................................................................
Income ..........................................................................................................................................................
Number of services .......................................................................................................................................
State ................................................................
Turnover .......................................................................................................................................................
Income ..........................................................................................................................................................
Number of services .......................................................................................................................................
State ................................................................
Turnover .......................................................................................................................................................
Income ..........................................................................................................................................................
Number of services .......................................................................................................................................
For further States please see attachment
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4. Declaration
I hereby declare that all information given corresponds to the actual circumstances. I am aware of the fact
that inspections may be carried out by the competent authorities, both in Germany and in the States where
I am pursuing activities, and that incorrect information in this questionnaire – also if given in error – may
lead to cancellation of the certificate A1 and thus to application of the legislation of another State. I will
immediately inform the GKV Spitzenverband, DVKA of any changes regarding my employment (e. g. transfer
of centre of vital interests, change of working times, taking up additional activities).
.............................................................................
................................................................................
Place and Date
Signature
Information on data protection:
The information contained in this request is required by the GKV-Spitzenverband, DVKA in order to meet its legally defined tasks.
Data is collected and electronically stored and used exclusively in compliance with regulations on data protection.
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