TN 1 (03-97)

GN 01714.105 Belgian Coverage Certification

A. Policy

Belgian coverage certifications are issued by the Belgian agency that has jurisdiction of the claim. Coverage certifications sent to DIO by any of the Belgian agencies contain a complete record of an individual's work in Belgium.

Each of the agencies and its branches uses a slightly different coverage form. The forms may be in Flemish or in French. However, the basic coverage information on all of the forms is the same.

In invalidity (disability cases), Belgium credits periods of coverage for years after the onset of disability up to retirement age. This is shown on the coverage certification as “nonwork” coverage, and it may be used by SSA.

B. Description of French language Belgian coverage record

The French language coverage record usually includes a cover sheet with information needed to identify the worker (name and date of birth). The form contains four columns of coverage information and a certification section. The following is a description of these items.

  1. Anneé(Year)

The first column shows the years 1926 to the present or just the years in which the worker has Belgian coverage.

  1. Periodes d'Assurance or Jours d'Assurance (Insurance Periods)

This column contains the periods of Belgian coverage that are based on work. It shows the total days of coverage for the year shown.

NOTE: Periods of Belgian coverage may be shown in quarters instead of days. If so, the column is headed "Nombre de Trimestres", and the number of quarters is shown for each year.

  1. Periodes Assimiles or Jours Assimilées (Converted Periods)

This column contains the periods of Belgian coverage that are not based on work. For example, this column contains periods of unemployment or periods of disability in Belgium. The column shows the total days of this type of coverage for the year shown.

  1. Profession

This column lists the type of work or type of “non-work” coverage period for each year.

  1. Belgian Agency Certification

The form usually contains the name of the agency that issued the coverage certification, the signature of the authorizing individual and the date.

C. Description of Flemish language coverage record

The beginning of the Flemish language coverage record contains information needed to identify the worker (name, date of birth, address, and U.S. and Belgian Social Security numbers). Information about Belgian coverage is shown in six columns, but DIO only uses the information in the first three columns. The bottom of the form contains a certification section. The following is a description of these items.

  1. Jaar (Year)

The first column shows the years in which the worker has Belgian coverage.

  1. Dagen van tewerkstelling (Days of employment)

This column contains the periods of Belgian coverage that are based on work. It shows the total days of coverage for the year.

NOTE: Periods of Belgian Coverage may be shown in quarters instead of days. If so, the column is headed "Kwartalen," and the number of quarters is shown for each year.

  1. Gelijkgestelde dagen (Equalized days)

This column contains the periods of Belgian coverage that are not based on work. For example, the column contains periods of unemployment or periods of disability in Belgium. The column shows the total days of this type of coverage for the year.

  1. Belgian Agency Certification

The last item on the form contains the signature of the authorizing official, the date and the agency that issued the coverage record.

D. French language coverage record

8
Années
Périods
d'assurance
Périodes
Assimilées
ProfessionObservations
     

 

 

  1. Institution qui remplit le formulaire

 

Denomination:

   

Adresse:
Cachet:

 

Date:
Signature:

 

E. Exhibit of Flemish language coverage record

 OVEREENKOMST OVER DE SOCIALE ZEKERHEID TUSSEN HET KONINKRIJK BELGIE EN DE VERENIGDE STATEN AMERIKA 

 

 Gegevens betreffende de verzekeringsloopbaan als werknemer in Belgie. 

 

 1. Arbeider 
 1.1  NAAM          VOORNAMEN         MEISJESNAAM 

 

 

 1.2  Geboortedatum: 
 1.3  Volledig adres: 
 1.4  U.S. Sociaal Zekerheidsnummer: 
 1.5  Belgisch inschrijvingsnummer: 

 

 2. Staat van de Belgische verzekeringstijdvakken 

 

 Jaar   Dagen van      Gelijkgestelde   Werkelijk   Fictief   Forfaitairloon 
        tewerkstelling      dagen        loon        loon (1)     voor 1955 (2) 

 

 

 

 Toegevoegde of bijkomende fictieve jaren: 

 

  1. Een fictief loon voor de gelijkgestelde dagen kan slechts worden vermeld als het Belgisch pensioen is toegekend.

  2. De forfaitaire lonen voor de jaren tot en met zijn aangepast aan het prijs - en welvaartsniveau an 1971. Aangepast tot op de ingangsdatum van het Belgisch pensioen [              ] bedraagt het loon per jaar:

     

                                                    fr. 

 

 Handtkening:                Datum:               Stempel: 

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201714105
GN 01714.105 - Belgian Coverage Certification - 06/12/2017
Batch run: 06/12/2017
Rev:06/12/2017