CA8454 - HM Revenue & Customs

Application for health care cover in the
European Economic Area
Why we are sending you this form
You may be able to get health care cover from the UK for you
and your dependants if you are resident in another country in
the European Economic Area (EEA), and are liable to pay UK
National Insurance contributions (NICs).
Or your dependants may have the right to health care cover
from the UK if they are living in another EEA country and you
are liable to pay UK NICs.
How to apply for health care cover
from the UK
Please fill in this form in black ink using capital letters. Show
dates in the format DD MM YYYY.
• If you are currently working for a UK employer you must
send us a copy of your latest payslip when you return this
form. Send the completed form with a copy of your latest
payslip to:
NIC&EO International Caseworker
HMRC
BP1301
Benton Park View
NEWCASTLE UPON TYNE
NE98 1ZZ
England
• If you are a mariner go to
www.hmrc.gov.uk/cnr/seafarersni.htm and fill in the
‘Mariners’ Questionnaire’ by following the link given on that
page. Then send this completed application form with a copy
of your:
– mariners’ discharge book
– latest payslip
– completed mariners’ questionnaire
to:
Marine NICs
HMRC
Phase 2, 15th Floor North Wing
Ty Glas Road
Llanishen
CARDIFF
CF14 5FP
Wales
If you need any help filling in the form, phone us on
+44 (0) 191 203 7010. If you need more space, please use
a separate sheet of paper and attach it to this form.
We may ask for evidence to confirm information given on this
application form.
Start date
Important: Your right to health cover depends on your liability
for UK NICs. This means that, depending on your
circumstances, the date from which you can get health cover
may differ from the one you ask for.
What happens next
We will send you a document to allow you to register in the
country of residence if you are able to get health care cover
from the UK.
More information
If you are resident abroad and normally carry out work in
more than one EEA country you should ask the social
security authorities in the country in which you reside which
country you should pay social security contributions to.
If you:
• need health care cover
• have recently left the UK, and
• are not working
you should contact the Department for Work and Pensions at
the following address:
Department for Work and Pensions
Overseas Healthcare Team
Room MO 135
Durham House
WASHINGTON
NE38 7SF
England
How we use your information
HM Revenue & Customs is a Data Controller under the
Data Protection Act 1998. We hold information for the
purposes specified in our notification to the Information
Commissioner, including the assessment and collection of
tax and duties, the payment of benefits and the prevention
and detection of crime, and may use this information for
any of them.
We may get information about you from others, or we may
give information to them. If we do, it will only be as the law
permits to:
• check the accuracy of information
• prevent or detect crime
• protect public funds.
We may check information we receive about you with what is
already in our records. This can include information provided
by you, as well as by others, such as other government
departments or agencies and overseas tax and customs
authorities. We will not give information to anyone outside
HM Revenue & Customs unless the law permits us to do so.
For more information go to www.hmrc.gov.uk and look for
Data Protection Act within the Search facility.
Your rights and obligations
Your Charter explains what you can expect from us and what
we expect from you. For more information go to
www.hmrc.gov.uk/charter
CA8454 Page 1 HMRC 02/13

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?
CA8454 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
CA8454 Page 3

2 Worker living abroad
29
What date did you move to your current country
32
Do you intend to return to the UK?
of residence? DD MM YYYY
Yes
No
If Yes, when do you intend to return? DD MM YYYY
30
In what country were you living before you moved to
your current country of residence?
If No, where do you intend to live in the long term?
31
Give your UK address immediately before leaving the UK
33
Do you maintain a home in the UK?
Yes
No
34
Do you have any dependants living in another EEA
Member State needing health care cover?
Yes go to Part 3
No
go to Declaration
3 Dependant’s details
Please check with the health care institution where you reside to see if an S1 is required for each dependant.
Some EEA Member States cover all dependants on one S1 form. If the health care institution confirms you need an S1
for each dependant then please also provide the name, address, date of birth, nationality and National Insurance number
(if they have one) of each dependant.
35
Full name of dependant
40
Full address
36
Date of birth DD MM YYYY
37
Place of birth
41
Does the dependant carry out any work in their country
of residence?
38
Country of residence
Yes No
If Yes, give details
39
UK National Insurance number
42
Social security number in their country of residence
CA8454 Page 4

Declaration
Checklist
I declare that the information given on this form is correct.
I will tell HMRC about any changes in circumstances.
Signature
Tick the boxes that apply to you.
I have filled in this form and signed the declaration.
I have enclosed a copy of my latest payslip.
Name
I am a mariner and I have enclosed a copy of my:
• mariners’ discharge book
Date DD MM YYYY
• completed mariners’ questionnaire.
Phone number
I am an agent and confirm that my client has sent
you a completed form 64-8 Authorising your agent.
I know that you cannot deal with me without
this authority.
CA8454 Page 5