Certificate of Coverage Request via Letter -Internet- Individuals (Poland)

Certificate of Coverage Request

CoC_Screen Captures_2016-06-14 for OMB Clearance (Poland)

Certificate of Coverage Request via Letter -Internet- Individuals (Poland)

OMB: 0960-0554

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CERTIFICATE OF
COVERAGE (COC)
External Web Page Screen
Captures

Table of Contents
Section

Pages

Section

Application Determination

3-4

Self-Employed Applications

Performer Application

5-7

Employer Applications

Pages

Australia

146-150

Austria

151-155

Australia

8-12

Belgium

156-160

Austria

13-17

Canada

161-165

Belgium

18-23

Chile

166-170

Canada

24-28

Czech Republic

171-175

Chile

29-33

Denmark

176-180

Czech Republic

34-38

Finland

181-185

Denmark

39-46

France

186-190

Finland

47-51

Germany

191-195

France

52-57

Greece

196-200

Germany

58-62

Ireland

201-205

Greece

63-67

Italy

206-210

Ireland

68-72

Japan

211-215

Italy

73-78

Korea (South)

216-220

Japan

79-83

Luxembourg

221-225

Korea (South)

84-88

Netherlands

226-230

Luxembourg

89-93

Norway

231-235

Netherlands

94-100

Poland

236-240

Norway

101-108

Portugal

241-245

Poland

109-113

Slovak Republic

246-250

Portugal

114-118

Spain

251-255

Slovak Republic

119-123

Sweden

256-260

Spain

124-128

Switzerland

261-265

Sweden

129-135

United Kingdom

266-270

Switzerland

136-140

United Kingdom

141-145

Certificate of Coverage Forms

Submission Confirmation

271

2

• Application Determination

Application Determination - 1 of 2

Certificate of Coverage Forms

3

• Application Determination

Application Determination - 2 of 2
(Non-Performer Only)

Certificate of Coverage Forms

4

• Performer Application

Performer Application – 1 of 3

Certificate of Coverage Forms

5

• Performer Application

Performer Application – 2 of 3

Certificate of Coverage Forms

6

• Performer Application

Performer Application – 3 of 3

Certificate of Coverage Forms

7

• Employer Application

Australia – 1 of 5

Certificate of Coverage Forms

8

• Employer Application

Australia – 2 of 5

Certificate of Coverage Forms

9

• Employer Application

Australia – 3 of 5

Certificate of Coverage Forms

10

• Employer Application

Australia – 4 of 5

Certificate of Coverage Forms

11

• Employer Application

Australia – 5 of 5

Certificate of Coverage Forms

12

• Employer Application

Austria – 1 of 5

Certificate of Coverage Forms

13

• Employer Application

Austria – 2 of 5

Certificate of Coverage Forms

14

• Employer Application

Austria – 3 of 5

Certificate of Coverage Forms

15

• Employer Application

Austria – 4 of 5

Certificate of Coverage Forms

16

• Employer Application

Austria – 5 of 5

Certificate of Coverage Forms

17

• Employer Application

Belgium – 1 of 6

Certificate of Coverage Forms

18

• Employer Application

Belgium – 2 of 6

Certificate of Coverage Forms

19

• Employer Application

Belgium – 3 of 6

Certificate of Coverage Forms

20

• Employer Application

Belgium – 4 of 6

Certificate of Coverage Forms

21

• Employer Application

Belgium – 5 of 6

Certificate of Coverage Forms

22

• Employer Application

Belgium – 6 of 6

Certificate of Coverage Forms

23

• Employer Application

Canada – 1 of 5

Certificate of Coverage Forms

24

• Employer Application

Canada – 2 of 5

Certificate of Coverage Forms

25

• Employer Application

Canada – 3 of 5

Certificate of Coverage Forms

26

• Employer Application

Canada – 4 of 5

Certificate of Coverage Forms

27

• Employer Application

Canada – 5 of 5

Certificate of Coverage Forms

28

• Employer Application

Chile – 1 of 5

Certificate of Coverage Forms

29

• Employer Application

Chile – 2 of 5

Certificate of Coverage Forms

30

• Employer Application

Chile – 3 of 5

Certificate of Coverage Forms

31

• Employer Application

Chile – 4 of 5

Certificate of Coverage Forms

32

• Employer Application

Chile – 5 of 5

Certificate of Coverage Forms

33

• Employer Application

Czech Republic – 1 of 5

Certificate of Coverage Forms

34

• Employer Application

Czech Republic – 2 of 5

Certificate of Coverage Forms

35

• Employer Application

Czech Republic – 3 of 5

Certificate of Coverage Forms

36

• Employer Application

Czech Republic – 4 of 5

Certificate of Coverage Forms

37

• Employer Application

Czech Republic – 5 of 5

Certificate of Coverage Forms

38

• Employer Application

Denmark – 1 of 8

Certificate of Coverage Forms

39

• Employer Application

Denmark – 2 of 8

Certificate of Coverage Forms

40

• Employer Application

Denmark – 3 of 8

Certificate of Coverage Forms

41

• Employer Application

Denmark – 4 of 8

Certificate of Coverage Forms

42

• Employer Application

Denmark – 5 of 8

Certificate of Coverage Forms

43

• Employer Application

Denmark – 6 of 8

Certificate of Coverage Forms

44

• Employer Application

Denmark – 7 of 8

Certificate of Coverage Forms

45

• Employer Application

Denmark – 8 of 8

Certificate of Coverage Forms

46

• Employer Application

Finland – 1 of 5

Certificate of Coverage Forms

47

• Employer Application

Finland – 2 of 5

Certificate of Coverage Forms

48

• Employer Application

Finland – 3 of 5

Certificate of Coverage Forms

49

• Employer Application

Finland – 4 of 5

Certificate of Coverage Forms

50

• Employer Application

Finland – 5 of 5

Certificate of Coverage Forms

51

• Employer Application

France – 1 of 6

Certificate of Coverage Forms

52

• Employer Application

France – 2 of 6

Certificate of Coverage Forms

53

• Employer Application

France – 3 of 6

Certificate of Coverage Forms

54

• Employer Application

France – 4 of 6

Certificate of Coverage Forms

55

• Employer Application

France – 5 of 6

Certificate of Coverage Forms

56

• Employer Application

France – 6 of 6

Certificate of Coverage Forms

57

• Employer Application

Germany – 1 of 5

Certificate of Coverage Forms

58

• Employer Application

Germany – 2 of 5

Certificate of Coverage Forms

59

• Employer Application

Germany – 3 of 5

Certificate of Coverage Forms

60

• Employer Application

Germany – 4 of 5

Certificate of Coverage Forms

61

• Employer Application

Germany – 5 of 5

Certificate of Coverage Forms

62

• Employer Application

Greece – 1 of 5

Certificate of Coverage Forms

63

• Employer Application

Greece – 2 of 5

Certificate of Coverage Forms

64

• Employer Application

Greece – 3 of 5

Certificate of Coverage Forms

65

• Employer Application

Greece – 4 of 5

Certificate of Coverage Forms

66

• Employer Application

Greece – 5 of 5

Certificate of Coverage Forms

67

• Employer Application

Ireland – 1 of 5

Certificate of Coverage Forms

68

• Employer Application

Ireland – 2 of 5

Certificate of Coverage Forms

69

• Employer Application

Ireland – 3 of 5

Certificate of Coverage Forms

70

• Employer Application

Ireland – 4 of 5

Certificate of Coverage Forms

71

• Employer Application

Ireland – 5 of 5

Certificate of Coverage Forms

72

• Employer Application

Italy – 1 of 6

Certificate of Coverage Forms

73

• Employer Application

Italy – 2 of 6

Certificate of Coverage Forms

74

• Employer Application

Italy – 3 of 6

Certificate of Coverage Forms

75

• Employer Application

Italy – 4 of 6

Certificate of Coverage Forms

76

• Employer Application

Italy – 5 of 6

Certificate of Coverage Forms

77

• Employer Application

Italy – 6 of 6

Certificate of Coverage Forms

78

• Employer Application

Japan – 1 of 5

Certificate of Coverage Forms

79

• Employer Application

Japan – 2 of 5

Certificate of Coverage Forms

80

• Employer Application

Japan – 3 of 5

Certificate of Coverage Forms

81

• Employer Application

Japan – 4 of 5

Certificate of Coverage Forms

82

• Employer Application

Japan – 5 of 5

Certificate of Coverage Forms

83

• Employer Application

South Korea – 1 of 5

Certificate of Coverage Forms

84

• Employer Application

South Korea – 2 of 5

Certificate of Coverage Forms

85

• Employer Application

South Korea – 3 of 5

Certificate of Coverage Forms

86

• Employer Application

South Korea – 4 of 5

Certificate of Coverage Forms

87

• Employer Application

South Korea – 5 of 5

Certificate of Coverage Forms

88

• Employer Application

Luxembourg – 1 of 5

Certificate of Coverage Forms

89

• Employer Application

Luxembourg – 2 of 5

Certificate of Coverage Forms

90

• Employer Application

Luxembourg – 3 of 5

Certificate of Coverage Forms

91

• Employer Application

Luxembourg – 4 of 5

Certificate of Coverage Forms

92

• Employer Application

Luxembourg – 5 of 5

Certificate of Coverage Forms

93

• Employer Application

Netherlands – 1 of 7

Certificate of Coverage Forms

94

• Employer Application

Netherlands – 2 of 7

Certificate of Coverage Forms

95

• Employer Application

Netherlands – 3 of 7

Certificate of Coverage Forms

96

• Employer Application

Netherlands – 4 of 7

Certificate of Coverage Forms

97

• Employer Application

Netherlands – 5 of 7

Certificate of Coverage Forms

98

• Employer Application

Netherlands – 6 of 7

Certificate of Coverage Forms

99

• Employer Application

Netherlands – 7 of 7

Certificate of Coverage Forms

100

• Employer Application

Norway – 1 of 8

Certificate of Coverage Forms

101

• Employer Application

Norway – 2 of 8

Certificate of Coverage Forms

102

• Employer Application

Norway – 3 of 8

Certificate of Coverage Forms

103

• Employer Application

Norway – 4 of 8

Certificate of Coverage Forms

104

• Employer Application

Norway – 5 of 8

Certificate of Coverage Forms

105

• Employer Application

Norway – 6 of 8

Certificate of Coverage Forms

106

• Employer Application

Norway – 7 of 8

Certificate of Coverage Forms

107

• Employer Application

Norway – 8 of 8

Certificate of Coverage Forms

108

• Employer Application

Poland – 1 of 5

Certificate of Coverage Forms

109

• Employer Application

Poland – 2 of 5

Certificate of Coverage Forms

110

• Employer Application

Poland – 3 of 5

Certificate of Coverage Forms

111

• Employer Application

Poland – 4 of 5

Certificate of Coverage Forms

112

• Employer Application

Poland – 5 of 5

Certificate of Coverage Forms

113

• Employer Application

Portugal – 1 of 5

Certificate of Coverage Forms

114

• Employer Application

Portugal – 2 of 5

Certificate of Coverage Forms

115

• Employer Application

Portugal – 3 of 5

Certificate of Coverage Forms

116

• Employer Application

Portugal – 4 of 5

Certificate of Coverage Forms

117

• Employer Application

Portugal – 5 of 5

Certificate of Coverage Forms

118

• Employer Application

Slovak Republic – 1 of 5

Certificate of Coverage Forms

119

• Employer Application

Slovak Republic – 2 of 5

Certificate of Coverage Forms

120

• Employer Application

Slovak Republic – 3 of 5

Certificate of Coverage Forms

121

• Employer Application

Slovak Republic – 4 of 5

Certificate of Coverage Forms

122

• Employer Application

Slovak Republic – 5 of 5

Certificate of Coverage Forms

123

• Employer Application

Spain – 1 of 5

Certificate of Coverage Forms

124

• Employer Application

Spain – 2 of 5

Certificate of Coverage Forms

125

• Employer Application

Spain – 3 of 5

Certificate of Coverage Forms

126

• Employer Application

Spain – 4 of 5

Certificate of Coverage Forms

127

• Employer Application

Spain – 5 of 5

Certificate of Coverage Forms

128

• Employer Application

Sweden – 1 of 7

Certificate of Coverage Forms

129

• Employer Application

Sweden – 2 of 7

Certificate of Coverage Forms

130

• Employer Application

Sweden – 3 of 7

Certificate of Coverage Forms

131

• Employer Application

Sweden – 4 of 7

Certificate of Coverage Forms

132

• Employer Application

Sweden – 5 of 7

Certificate of Coverage Forms

133

• Employer Application

Sweden – 6 of 7

Certificate of Coverage Forms

134

• Employer Application

Sweden – 7 of 7

Certificate of Coverage Forms

135

• Employer Application

Switzerland – 1 of 5

Certificate of Coverage Forms

136

• Employer Application

Switzerland – 2 of 5

Certificate of Coverage Forms

137

• Employer Application

Switzerland – 3 of 5

Certificate of Coverage Forms

138

• Employer Application

Switzerland – 4 of 5

Certificate of Coverage Forms

139

• Employer Application

Switzerland – 5 of 5

Certificate of Coverage Forms

140

• Employer Application

United Kingdom – 1 of 5

Certificate of Coverage Forms

141

• Employer Application

United Kingdom – 2 of 5

Certificate of Coverage Forms

142

• Employer Application

United Kingdom – 3 of 5

Certificate of Coverage Forms

143

• Employer Application

United Kingdom – 4 of 5

Certificate of Coverage Forms

144

• Employer Application

United Kingdom – 5 of 5

Certificate of Coverage Forms

145

• Self-Employed Application

Australia – 1 of 5

Certificate of Coverage Forms

146

• Self-Employed Application

Australia – 2 of 5

Certificate of Coverage Forms

147

• Self-Employed Application

Australia – 3 of 5

Certificate of Coverage Forms

148

• Self-Employed Application

Australia – 4 of 5

Certificate of Coverage Forms

149

• Self-Employed Application

Australia – 5 of 5

Certificate of Coverage Forms

150

• Self-Employed Application

Austria – 1 of 5

Certificate of Coverage Forms

151

• Self-Employed Application

Austria – 2 of 5

Certificate of Coverage Forms

152

• Self-Employed Application

Austria – 3 of 5

Certificate of Coverage Forms

153

• Self-Employed Application

Austria – 4 of 5

Certificate of Coverage Forms

154

• Self-Employed Application

Austria – 5 of 5

Certificate of Coverage Forms

155

• Self-Employed Application

Belgium – 1 of 5

Certificate of Coverage Forms

156

• Self-Employed Application

Belgium – 2 of 5

Certificate of Coverage Forms

157

• Self-Employed Application

Belgium – 3 of 5

Certificate of Coverage Forms

158

• Self-Employed Application

Belgium – 4 of 5

Certificate of Coverage Forms

159

• Self-Employed Application

Belgium – 5 of 5

Certificate of Coverage Forms

160

• Self-Employed Application

Canada – 1 of 5

Certificate of Coverage Forms

161

• Self-Employed Application

Canada – 2 of 5

Certificate of Coverage Forms

162

• Self-Employed Application

Canada – 3 of 5

Certificate of Coverage Forms

163

• Self-Employed Application

Canada – 4 of 5

Certificate of Coverage Forms

164

• Self-Employed Application

Canada – 5 of 5

Certificate of Coverage Forms

165

• Self-Employed Application

Chile – 1 of 5

Certificate of Coverage Forms

166

• Self-Employed Application

Chile – 2 of 5

Certificate of Coverage Forms

167

• Self-Employed Application

Chile – 3 of 5

Certificate of Coverage Forms

168

• Self-Employed Application

Chile – 4 of 5

Certificate of Coverage Forms

169

• Self-Employed Application

Chile – 5 of 5

Certificate of Coverage Forms

170

• Self-Employed Application

Czech Republic – 1 of 5

Certificate of Coverage Forms

171

• Self-Employed Application

Czech Republic – 2 of 5

Certificate of Coverage Forms

172

• Self-Employed Application

Czech Republic – 3 of 5

Certificate of Coverage Forms

173

• Self-Employed Application

Czech Republic – 4 of 5

Certificate of Coverage Forms

174

• Self-Employed Application

Czech Republic – 5 of 5

Certificate of Coverage Forms

175

• Self-Employed Application

Denmark – 1 of 5

Certificate of Coverage Forms

176

• Self-Employed Application

Denmark – 2 of 5

Certificate of Coverage Forms

177

• Self-Employed Application

Denmark – 3 of 5

Certificate of Coverage Forms

178

• Self-Employed Application

Denmark – 4 of 5

Certificate of Coverage Forms

179

• Self-Employed Application

Denmark – 5 of 5

Certificate of Coverage Forms

180

• Self-Employed Application

Finland – 1 of 5

Certificate of Coverage Forms

181

• Self-Employed Application

Finland – 2 of 5

Certificate of Coverage Forms

182

• Self-Employed Application

Finland – 3 of 5

Certificate of Coverage Forms

183

• Self-Employed Application

Finland – 4 of 5

Certificate of Coverage Forms

184

• Self-Employed Application

Finland – 5 of 5

Certificate of Coverage Forms

185

• Self-Employed Application

France – 1 of 5

Certificate of Coverage Forms

186

• Self-Employed Application

France – 2 of 5

Certificate of Coverage Forms

187

• Self-Employed Application

France – 3 of 5

Certificate of Coverage Forms

188

• Self-Employed Application

France – 4 of 5

Certificate of Coverage Forms

189

• Self-Employed Application

France – 5 of 5

Certificate of Coverage Forms

190

• Self-Employed Application

Germany – 1 of 5

Certificate of Coverage Forms

191

• Self-Employed Application

Germany – 2 of 5

Certificate of Coverage Forms

192

• Self-Employed Application

Germany – 3 of 5

Certificate of Coverage Forms

193

• Self-Employed Application

Germany – 4 of 5

Certificate of Coverage Forms

194

• Self-Employed Application

Germany – 5 of 5

Certificate of Coverage Forms

195

• Self-Employed Application

Greece – 1 of 5

Certificate of Coverage Forms

196

• Self-Employed Application

Greece – 2 of 5

Certificate of Coverage Forms

197

• Self-Employed Application

Greece – 3 of 5

Certificate of Coverage Forms

198

• Self-Employed Application

Greece – 4 of 5

Certificate of Coverage Forms

199

• Self-Employed Application

Greece – 5 of 5

Certificate of Coverage Forms

200

• Self-Employed Application

Ireland – 1 of 5

Certificate of Coverage Forms

201

• Self-Employed Application

Ireland – 2 of 5

Certificate of Coverage Forms

202

• Self-Employed Application

Ireland – 3 of 5

Certificate of Coverage Forms

203

• Self-Employed Application

Ireland – 4 of 5

Certificate of Coverage Forms

204

• Self-Employed Application

Ireland – 5 of 5

Certificate of Coverage Forms

205

• Self-Employed Application

Italy – 1 of 5

Certificate of Coverage Forms

206

• Self-Employed Application

Italy – 2 of 5

Certificate of Coverage Forms

207

• Self-Employed Application

Italy – 3 of 5

Certificate of Coverage Forms

208

• Self-Employed Application

Italy – 4 of 5

Certificate of Coverage Forms

209

• Self-Employed Application

Italy – 5 of 5

Certificate of Coverage Forms

210

• Self-Employed Application

Japan – 1 of 5

Certificate of Coverage Forms

211

• Self-Employed Application

Japan – 2 of 5

Certificate of Coverage Forms

212

• Self-Employed Application

Japan – 3 of 5

Certificate of Coverage Forms

213

• Self-Employed Application

Japan – 4 of 5

Certificate of Coverage Forms

214

• Self-Employed Application

Japan – 5 of 5

Certificate of Coverage Forms

215

• Self-Employed Application

South Korea – 1 of 5

Certificate of Coverage Forms

216

• Self-Employed Application

South Korea – 2 of 5

Certificate of Coverage Forms

217

• Self-Employed Application

South Korea – 3 of 5

Certificate of Coverage Forms

218

• Self-Employed Application

South Korea – 4 of 5

Certificate of Coverage Forms

219

• Self-Employed Application

South Korea – 5 of 5

Certificate of Coverage Forms

220

• Self-Employed Application

Luxembourg – 1 of 5

Certificate of Coverage Forms

221

• Self-Employed Application

Luxembourg – 2 of 5

Certificate of Coverage Forms

222

• Self-Employed Application

Luxembourg – 3 of 5

Certificate of Coverage Forms

223

• Self-Employed Application

Luxembourg – 4 of 5

Certificate of Coverage Forms

224

• Self-Employed Application

Luxembourg – 5 of 5

Certificate of Coverage Forms

225

• Self-Employed Application

Netherlands – 1 of 5

Certificate of Coverage Forms

226

• Self-Employed Application

Netherlands – 2 of 5

Certificate of Coverage Forms

227

• Self-Employed Application

Netherlands – 3 of 5

Certificate of Coverage Forms

228

• Self-Employed Application

Netherlands – 4 of 5

Certificate of Coverage Forms

229

• Self-Employed Application

Netherlands – 5 of 5

Certificate of Coverage Forms

230

• Self-Employed Application

Norway – 1 of 5

Certificate of Coverage Forms

231

• Self-Employed Application

Norway – 2 of 5

Certificate of Coverage Forms

232

• Self-Employed Application

Norway – 3 of 5

Certificate of Coverage Forms

233

• Self-Employed Application

Norway – 4 of 5

Certificate of Coverage Forms

234

• Self-Employed Application

Norway – 5 of 5

Certificate of Coverage Forms

235

• Self-Employed Application

Poland – 1 of 5

Certificate of Coverage Forms

236

• Self-Employed Application

Poland – 2 of 5

Certificate of Coverage Forms

237

• Self-Employed Application

Poland – 3 of 5

Certificate of Coverage Forms

238

• Self-Employed Application

Poland – 4 of 5

Certificate of Coverage Forms

239

• Self-Employed Application

Poland – 5 of 5

Certificate of Coverage Forms

240

• Self-Employed Application

Portugal – 1 of 5

Certificate of Coverage Forms

241

• Self-Employed Application

Portugal – 2 of 5

Certificate of Coverage Forms

242

• Self-Employed Application

Portugal – 3 of 5

Certificate of Coverage Forms

243

• Self-Employed Application

Portugal – 4 of 5

Certificate of Coverage Forms

244

• Self-Employed Application

Portugal – 5 of 5

Certificate of Coverage Forms

245

• Self-Employed Application

Slovak Republic – 1 of 5

Certificate of Coverage Forms

246

• Self-Employed Application

Slovak Republic – 2 of 5

Certificate of Coverage Forms

247

• Self-Employed Application

Slovak Republic – 3 of 5

Certificate of Coverage Forms

248

• Self-Employed Application

Slovak Republic – 4 of 5

Certificate of Coverage Forms

249

• Self-Employed Application

Slovak Republic – 5 of 5

Certificate of Coverage Forms

250

• Self-Employed Application

Spain – 1 of 5

Certificate of Coverage Forms

251

• Self-Employed Application

Spain – 2 of 5

Certificate of Coverage Forms

252

• Self-Employed Application

Spain – 3 of 5

Certificate of Coverage Forms

253

• Self-Employed Application

Spain – 4 of 5

Certificate of Coverage Forms

254

• Self-Employed Application

Spain – 5 of 5

Certificate of Coverage Forms

255

• Self-Employed Application

Sweden – 1 of 5

Certificate of Coverage Forms

256

• Self-Employed Application

Sweden – 2 of 5

Certificate of Coverage Forms

257

• Self-Employed Application

Sweden – 3 of 5

Certificate of Coverage Forms

258

• Self-Employed Application

Sweden – 4 of 5

Certificate of Coverage Forms

259

• Self-Employed Application

Sweden – 5 of 5

Certificate of Coverage Forms

260

• Self-Employed Application

Switzerland – 1 of 5

Certificate of Coverage Forms

261

• Self-Employed Application

Switzerland – 2 of 5

Certificate of Coverage Forms

262

• Self-Employed Application

Switzerland – 3 of 5

Certificate of Coverage Forms

263

• Self-Employed Application

Switzerland – 4 of 5

Certificate of Coverage Forms

264

• Self-Employed Application

Switzerland – 5 of 5

Certificate of Coverage Forms

265

• Self-Employed Application

United Kingdom – 1 of 5

Certificate of Coverage Forms

266

• Self-Employed Application

United Kingdom – 2 of 5

Certificate of Coverage Forms

267

• Self-Employed Application

United Kingdom – 3 of 5

Certificate of Coverage Forms

268

• Self-Employed Application

United Kingdom – 4 of 5

Certificate of Coverage Forms

269

• Self-Employed Application

United Kingdom – 5 of 5

Certificate of Coverage Forms

270

• Submission Confirmation

Submission Confirmation – 1 of 1

Certificate of Coverage Forms

271


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