verklaring (E) 101/Application for (E) 101 certificate

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1 Aanvraag/Application Verzekeringen verklaring (E) 101/Application for (E) 101 certificate Met dit formulier vraagt u een verklaring aan waarmee uw werknemers kunnen aantonen dat zij in Nederland sociaal verzekerd zijn als zij buiten Nederland werken. Use this form to apply for a certificate with which your employees can show that they are covered by Dutch social security legislation while working outside the Netherlands. 1 Gegevens werkgever Employer details loonheffingennummer tax and national insurance reference naam van de onderneming (statutaire tenaamstelling) name of company (statutory name) postbusnummer P.O. Box number postcode en plaats land country naam contactpersoon name of contact telefoon contactpersoon telephone number of contact adres address Heeft u minimaal 3 andere werknemers in dienst die uitsluitend in Nederland werken Do you have at least 3 other employees who exclusively work in the Netherlands Zijn uw werknemers ambtenaar Are your employees civil servants 2 Ondertekening Signature Ondergetekende verklaart dat alle vragen naar waarheid zijn beantwoord. Tevens verklaart hij/zij ervan op de hoogte te zijn dat door zowel de SVB als de bevoegde autoriteiten in het buitenland controle kan worden uitgevoerd. I declare that I have answered all the questions correctly to the best of my kwledge. I also declare that I am aware that both the SVB and the competent authorities outside the Netherlands may verify the information entered. plaats place datum date handtekening werkgever / gemachtigde * signature of employer / representative* * doorhalen wat niet van toepassing is * delete as applicable Als u een gemachtigde bent, moet u eenmalig een door de werkgever ondertekende machtiging bijvoegen. If you are a representative, you must enclose one authorization, signed by the employer.

2 3 Gegevens werknemer Employee details sofi-nummer dutch tax number (SoFi No.) De originele verklaring (E) 101 zal naar het hieronder door u vermelde adres worden gestuurd. The original (E) 101 certificate will be sent to the address you specify below. achternaam surname voorvoegsels (voluit) prefix(es) voornamen (eerste voluit) forename(s) meisjesnaam maiden name voorvoegsels (voluit) prefix(es) geboortedatum date of birth Heeft de werknemer de Nederlandse nationaliteit Does the employee have Dutch nationality, de nationaliteit nationality Woont de werknemer in Nederland Does the employee live in the Netherlands straat en huisnummer street and number postcode en woonplaats, (tijdelijk) woonadres in het buitenland:, (temporary) home address outside the Netherlands: straat en huisnummer street and number postcode en woonplaats land country 4 Beoordelingsgegevens Assessment details Wanr gaat de werknemer buiten Nederland werken Als dit g niet bekend is, geef hier aan voor welke periode u de verklaring wilt aanvragen. When is the employee going to start working outside the Netherlands If this is t yet kwn, indicate for what period you wish to apply for the certificate. Bij het werken in één of meer EU-lidstaten is het voor de vaststelling van de toe te passen wetgeving van belang te weten hoe vaak men buiten Nederland werkt en hoe vaak in Nederland. Zie ook de toelichting. In the event of employment in one or more EU Member States, it is necessary to kw how often an employee works outside and how often within the Netherlands when the applicable legislation is determined. See also the explanatory tes. tot en met up to and including In welk(e) land(en) werkt de werknemer In what country/ies does the employee work? Vul één van de opties in Complete one of the options de werknemer werkt op één locatie: the employee works at one location:

3 naam onderneming tewerkstelling name of company where the employee works straat en huisnummer street and number postcode en woonplaats de werknemer werkt op diverse locaties the employee works at various locations de werknemer werkt in een project the employee is involved in a project Werkt de werknemer als chauffeur bij een internationaal transportbedrijf Does the employee work as a driver with an international transport company Werkt de werknemer op een schip of als baggeraar Does the employee work on a ship, or as a dredger Blijft gedurende het werken buiten Nederland de dienstbetrekking in stand Is the employer-employee relationship maintained during the period of work outside the Netherlands Betaalt u gedurende het werken buiten Nederland het loon door Are you continuing to pay wages while the employee works outside the Netherlands Draagt u premie af in Nederland gedurende het werken buiten Nederland Are you paying contributions in the Netherlands while the employee is working outside the Netherlands Vul één van de opties in Complete one of the options LET OP: De perioden in deze vraag zijn gewijzigd NB The application periods in this question have been changed. projectnaam project name De periode die u aanvraagt is korter dan een maand. Your application is for a period of less than a month. Werkt de werknemer in deze periode ook minimaal Ga naar 6. een dag in Nederland? Proceed to question 6. Will the employee also work at least one day in the Netherlands during this period? Heeft de werknemer direct voorafgaande aan de detachering ten minste 4 weken in Nederland gewerkt Did the employee work in the Netherlands for at least 4 weeks immediately prior to the secondment De periode die u aanvraagt is langer dan een maand. Your application is for a period longer than a month. Werkt de werknemer in deze periode ook gemiddeld Ga naar 6. een dag of meer per maand in Nederland? Proceed to question 6. Will the employee also be working on average one day or more per month in the Netherlands during this period?

4 Zendt u de werknemer uit ter vervanging van een andere gedetacheerde werknemer Are you posting the employee to replace ather employee who has been posted Heeft de werknemer in de 3 maanden voorafgaande aan de detachering al buiten Nederland gewerkt Has the employee worked outside the Netherlands during the 3 months prior to the secondment 5 Gezinsleden Family members Gezinsleden die de werknemer vergezellen Family members accompanying the employee 6 Artiesten/musici Performing artists/musicians Zie toelichting. Alleen invullen bij detachering naar de Verenigde Staten, Canada, Noorwegen, Israël, Australië of Zuid-Korea. See explanatory tes. Only complete this section in the case of secondment to the United States of America, Canada, Norway, Israel, Australia or South Korea. voorletters en (meisjes)naam geboortedatum sofi-nr initials and (maiden)name date of birth SoFi No. Zie toelichting. See explanatory tes. Treedt betrokkene in het buitenland op voor de werkgever in vraag 1 Does the person concerned perform outside the Netherlands for the employer named in section 1 Zo, is betrokkene in het bezit van een zelfstandigheidsverklaring artiesten of een Verklaring Arbeidsrelatie (VAR) van de belastingdienst If t, is he/she in possession of a self-employment declaration for performing artists or a VAR declaration (declaration of labour relationship) from the tax authorities Stuur een kopie mee. Enclose a copy., betrokkene werkt in Nederland voor, the person concerned works in the Netherlands for één opdracht / werkgever one client / employer meer dan één opdracht / werkgever more than one client / employer 7 Meesturen Enclosures De volgende bijlagen worden met de aanvraag meegestuurd Tick the documents you are enclosing with the application kopie zelfstandigheidsverklaring of VAR copy of self-employment declaration or VAR declaration bijlage meerdere werkgevers enclosure for multiple employers bijlage meerdere gezinsleden enclosure for more than three family members machtigingsformulier authorization form

5 8 Ondertekening Signature datum date handtekening werkgever / werknemer/ gemachtigde / artiest / musicus * signature of employer / employee/ representative/ performing artist / musician* * doorhalen wat niet van toepassing is * delete as applicable Als u een gemachtigde bent, voeg dan eenmalig een door de werkgever ondertekende machtiging bij. If you are a representative, you must enclose an authorization, signed by the employer (you only d to send an authorization once.) Stuur dit formulier en eventuele bijlagen naar de Sociale Verzekeringsbank, Kantoor Verzekeringen, Postbus 357, 1180 AJ Amstelveen. Als u vragen heeft kunt u bellen naar telefoonnummer (020) Send this form and any enclosures to: SVB, Kantoor Verzekeringen, Postbus 357, 1180 AJ Amstelveen, the Netherlands. If you have any questions, you may call No

6 (E) 101 CERTIFICATE APPLICATION FORM: NOTES GENERAL Multiple employees The employer form only has to be filled in once if an application is submitted for several employees simultaneously. Multiple employers If there are multiple employers, attach a separate sheet with the employer form containing the details of section 1 for the other employers. If the person concerned has a self-employment declaration for performing artists, or a VAR (labour relationship declaration) from the tax authorities, send in a copy of that declaration. Child benefit entitlement If the employee receives child benefit, it is important that he or she sends a copy of the (E) 101 certificate to the SVB office serving his or her area. These are: Australia, Belgium, Bulgaria, Bosnia-Herzegovina, Canada, Chili, Denmark, Germany, Estonia, Federal Republic of Yugoslavia, Finland, France, Greece, UK, Hungary, Ireland, Israel, Italy, Cape Verde, Croatia, Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, Malta, Morocco, New-Zealand, Norway, Austria, Poland, Portugal, Romania, Slovenia, Slovakia, Spain, Czech Republic,Turkey,Tunesia, United States of America, Iceland, South Korea, Sweden and Switzerland. Authorization (see sections 3 and 8) If you have a representative acting on your behalf, for example, tax consultancies and accountancy firms, you must send an authorization with the first application. You can phone us to ask for an authorization form. Please te that all correspondence will then be sent to the representative. Dutch health insurance An employee who is covered by Dutch national health insurance must apply for a European health insurance card from his/her health care insurer.this card entitles the employee to medical provisions outside the Netherlands. EMPLOYER DETAILS Tax and national insurance reference We d this reference for the secondment of your employee(s). This is necessary with regard to the payment of contributions and the insurance of your employee(s). For which countries can a secondment certificate be issued? Secondment certificates can only be issued for work in EU/EEA countries and countries with which the Netherlands has concluded an agreement on social security. Business activities in the Netherlands One of the conditions you must meet before you can post your employees outside the Netherlands is that your company generally carries out its business activities in the Netherlands. We check this by asking whether you have at least 3 other employees who exclusively work in the Netherlands. 7

7 ASSESSMENT DETAILS When are people insured under the Dutch national and industrial insurance schemes? People are generally insured under the Dutch national and industrial insurance schemes if they: work in the Netherlands, or perform work outside the Netherlands for which a secondment certificate has been issued. People are only insured under Dutch national insurance if they: do t work, but live in the Netherlands. An (E)101 certificate can only be issued if the person concerned is insured under Dutch national and industrial insurance immediately prior to the date of secondment. That is why the form asks whether the employee worked in the Netherlands for at least 4 weeks immediately prior to being seconded. If t, you must enclose documentary evidence showing that the employee was insured under Dutch national and industrial insurance immediately prior to secondment. Such documentary evidence can be payslips, statements of expenses, etc. FAMILY MEMBERS Co-insured family members Family members who accompany the seconded employee to the USA (5 years), Australia (5 years), Canada (2 years), Israel (5 years), Norway (5 years) and South Korea (5 years) are considered as having continued to reside in the Netherlands for at most the period stated between the brackets. That means that they continue to be insured under the Dutch national insurance schemes unless they start working in the country to which the employee was posted. If more than 3 family members accompany the employee, you must send their details in a separate enclosure. SVB, KANTOOR VERZEKERINGEN (020) Postbus AJ Amstelveen The Netherlands Performing artists / musicians The tax authorities may issue a performing artist / musician with a self-employment declaration or a labour relationship declaration (VAR) for wage tax and national insurance purposes. To be self-employed, the performing artist / musician must carry out his or her work for his or her own company, or on a freelance basis. Performing artists / musicians without a selfemployment declaration as considered as employees. There are two possible situations: The performing artist/musician works in the employ of one client/employer; The performing artist/musician has temporary employment relationships with various clients / employers (in this case, it is t necessary to provide employer details). SIGNATURE Incorrect details in the application form can lead to cancellation if necessary, with retroactive effect of the certificates issued, and consequently to application of the n-dutch social security legislation. Family members who are t co-insured Family members who accompany the seconded employee to a country other than the countries named above, will longer be covered by the Dutch social insurance schemes. They will, however, have the possibility of taking out voluntary AOW old age pension or Anw survivor s benefit insurance. For more information about this, they can contact: 8

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