BO HIM X HI VIT NAM

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

T KHAI THAM GIA

nh
3x4

Mu s: A01-TS
(Ban hnh km theo Q s: 1111 /Q-BHXH
ngy 25./10./2011 ca BHXH Vit Nam)

BO HIM X HI, BO HIM Y T

M s: __________________________

I. THNG TIN CA NGI THAM GIA:

[01]. H v tn (vit ch in hoa):_______________________, [02]. Gii tnh: Nam N

[03]. Ngy thng nm sinh: __/__/_____, [04]. Dn tc:______, [05]. Quc tch:________
[06]. H khu thng tr hoc tm tr:_________________________________________
[07]. a ch lin h:________________________________________________________
[08]. S in thoi lin h (nu c): c nh: ________________, di ng: ______________
[09]. CMT s:_____________, ngy cp:____/____/_____, ni cp:__________________
II. THAM GIA BO HIM X HI BT BUC, BO HIM Y T:

[10]. Quyt nh tuyn dng, hp ng lao ng (hoc HLV): s___________________

ngy ___/___/_____ c hiu lc t ngy ___/___/_____ loi hp ng _______________
[11]. Tn c quan, n v, a ch: ____________________________________________
________________________________________________________________________
[12]. Ni lm vic:_________________________________________________________
[13]. Chc v, chc danh ngh, cng vic: ______________________________________
________________________________________________________________________
[14]. Lng chnh: ___________________________,
[15]. Ph cp: [15.1]. PCCV___, [15.2]. TNN____, [15.3]. TNVK____, [15.4]. Khc ____
[16]. M s s bo him x hi c cp (nu c):_______________________________
[17]. M s th bo him y t c cp (nu c):________________________________
[18]. Ni ng k khm cha bnh ban u (theo hng dn ca c quan BHXH): ____________
________________________________________________________________________
[19]. Quyn li hng bo him y t (nu c):_____________________________________
Xc nhn ca ngi s dng lao ng
Ti xin cam oan nhng ni dung k khai Sau khi kim tra, i chiu xc nhn cc ni
trn l ng s tht v xin chu hon ton dung k khai trn l ng v xin chu hon
trch nhim trc php lut.
ton trch nhim trc php lut.
.........., ngy ....... thng ....... nm ...........
.........., ngy ....... thng ....... nm ...........
Ngi khai
Th trng n v
(K, ghi r h tn)
(K, ghi r h tn v ng du)
Duyt ca c quan bo him x hi:

Cn b thu
(K, ghi r h tn)

Cn b s, th
(K, ghi r h tn)

........., ngy...... thng...... nm .........

Gim c BHXH
(K, ghi r h tn v ng du)

PH LC: THI GIAN LM VIC C NG BHXH

CHA HNG MT LN
T
thn
g
nm

n
thng
nm

Din gii

Cn c
ng

T l ng (%)

BHXH BHTN
5

Mu s: D01b-TS
(Ban hnh km theo Q s:1111/Q-BHXH
ngy 25/10/2011 ca BHXH Vit Nam)

n v:..........
S:.....................

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

................, ngy ..... thng ..... nm ...........

Knh gi: Bo him x hi.............................................

- Tn n v:..................................................................................................
- M s qun l:.............................................................................................
- a ch:.....................................................................in thoi:.................
Ni dung:
.................................................................................................................................
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.................................................................................................................................
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L do:
.................................................................................................................................
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H s gi km:
.................................................................................................................................
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.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
ngh c quan bo him x hi xem xt, gii quyt theo quy nh.
Th trng n v
(k, ng du v ghi r h tn)

Tn n v:...........................
M s:...................................
in thoi:............................

DANH SCH NGH

(Km theo cng vn s:.................... ngy......................)
STT

H v tn

S s

Ni dung ngh

Mi

Cn c iu chnh

Lu : i vi cc trng hp thai sn v m au cn cp th BHYT ngh n v lp thm mu D02-TS ng 4,5% ca hn th.