BO HIM X HI VIT NAM

Ph lc: H THNG CHNG T, S, BIU MU QUN L THU BHXH, BHYT; QUN L S BHXH, TH BHYT
(Ban hnh km theo Quyt nh s: ..................../Q-BHXH ngy .........../.........../2011 ca BHXH Vit Nam)
S TT 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Tn mu biu 2
T khai tham gia BHXH, BHYT T khai tham gia BHXH t nguyn T khai tham gia BHYT n ngh Vn bn ngh ca n v Danh sch lao ng tham gia BHXH, BHYT Tng hp danh sch lao ng tham gia BHXH, BHYT Danh sch ngi ch tham gia BHYT Tng hp danh sch ngi ch tham gia BHYT Danh sch iu chnh mc ng cho ngi ch tham gia BHYT Tng hp danh sch iu chnh mc ng cho ngi ch tham gia BHYT Danh sch ngi tham gia BHXH T nguyn Tng hp danh sch ngi tham gia BHXH T nguyn Danh sch gim ngi tham gia BHXH T nguyn Danh sch ngh thay i thng tin ca ngi tham gia khng thay i mc ng Tng hp danh sch ngh thay i thng tin ca ngi tham gia khng thay i mc ng Danh sch i tng n hn phi ng BHXH, BHYT T nguyn Danh sch cp s BHXH Danh sch cp th BHYT Tng hp s phi thu BHXH, BHYT Phiu iu chnh Bin bn thm nh s liu thu np BHXH, BHYT Hp ng ng BHYT Bin bn thanh l hp ng ng BHYT Bin bn i chiu thu np BHXH, BHYT Phiu s dng phi ba s BHXH Phiu s dng phi th BHYT Phiu giao nhn phi s BHXH, th BHYT

K hiu 3
A01-TS A02-TS A03-TS D01-TS D01b-TS D02-TS D02a-TS D03-TS D03a-TS D04-TS D04a-TS D05-TS D05a-TS D06a-TS D07-TS D07a-TS D08a-TS D09a-TS D10a-TS C01-TS C02-TS C03-TS C04-TS C04a-TS C05-TS C06-TS C07-TS C08-TS

Thi gian lp 4
Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Khi c pht sinh Hng thng Khi c pht sinh Khi c pht sinh Ngy 01 hng thng Khi c pht sinh Qu, nm Hng nm Hng nm Hng qu Khi c pht sinh Khi c pht sinh Khi c pht sinh

S bn Trch nhim lp lp 5 6
01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 02 02 01 01 02 02 02 02 02 02 02 Ngi tham gia Ngi tham gia Ngi tham gia Ngi tham gia n v n v Thu n v/i l Thu n v/i l Thu i l Thu Thu n v Thu Thu Cp s th Cp s th Thu B phn lin quan

Ni nhn 7
n v n v n v BHXH BHXH BHXH Cp s th BHXH Cp s th BHXH Cp s th BHXH Cp s th Cp s th BHXH Cp s th i l n v n v Cp s th B phn lin quan

Ghi ch 8

Lp cho thng sau, km thng bo thng

Phng thu, Ban Thu BHXH cp trn B phn thu, KHTC n v qun l B phn thu, KHTC n v qun l Thu Chuyn qun Chuyn qun Cp s th C quan lin quan

Chuyn qun

S TT 1
29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Tn mu biu 2
Phiu giao nhn h s Bin bn hy s BHXH, th BHYT Bin bn thu hi, tm gi th BHYT Thng bo kt qu ng BHXH, BHYT (n v) T.bo K.qu ng BHXH, BHTN, BHYT (ngi lao ng) Thng bo kt qu ng BHXH T nguyn, BHYT (i l) Xc nhn thi gian ng BHTN cha hng S theo di s phi thu BHXH, BHYT S theo di s phi thu BHYT c h tr ca ngn sch S theo di qu trnh ng BHXH S theo di s dng phi s BHXH S theo di tnh hnh cp s BHXH S chi tit s dng phi th BHYT S chi tit thi hn s dng th BHYT Bo co ch tiu qun l thu, cp s BHXH, th BHYT Bo co tnh hnh thu BHXH, BHYT Bo co tng hp tnh hnh thu BHXH, BHYT Bo co chi tit n v n

K hiu 3
C09-TS C10-TS C11-TS C12-TS C13-TS C14-TS C15-TS S01-TS S02-TS S03-TS S04-TS S05-TS S06-TS S07-TS B01-TS B02a-TS B02b-TS B03-TS

Thi gian lp 4
Khi c pht sinh Hng nm Khi c pht sinh Hng thng Hng nm Hng thng Khi c pht sinh hng thng Hng thng Thng 12 Hng thng Hng thng Hng thng Hng thng Hng thng (qu) hng qu hng qu Hng thng

S bn Trch nhim lp lp 5 6
01 02 02 02 02 02 01 01 02 01 01 01 01 04 01 01 01 B phn lin quan Cp s th Cp s th Thu Thu Thu B phn CS BHXH Thu Thu Cp s th Chuyn qun Cp s th Chuyn qun Chuyn qun Thu; S, th Thu Thu Thu

Ni nhn 7
B phn lin quan BHXH VN Ngi tham gia n v Ngi tham gia i l Ngi tham gia

Ghi ch 8

n v Cp s th Cp s th Cp s th BHXH cp trn Lu ti BHXH tnh, huyn Lu ti BHXH tnh BHXH VN

Bo co truy thu BHXH, BHYT, BHTN Bo co truy thu BHXH, BHYT, BHTN
Bng tng hp s th v s phi thu theo ni ng k KCB ban u K hoch thu BHXH, BHYT K hoch s dng phi s BHXH, th BHYT S cc quy trnh qun l thu BHXH, BHYT; qun l s BHXH, th BHYT

B04a-TS B04b-TS
B05-TS K01-TS K02-TS

Hng qu Hng qu
Hng thng Hng nm Hng nm

01 01
01 01 01

Thu Thu
Phng thu Thu Cp s th

BHXH tnh BHXH Vit Nam

Phng G.nh BHXH cp trn BHXH VN

BO HIM X HI VIT NAM

Tn n v: M n v: in thoi lin h:

DANH SCH LAO NG THAM GIA BHXH, BHYT

S: thng .. nm ...
Mu D02 (Ban hnh km theo Q s: 1111/Q ngy 25/10/2011 ca BHXH Vit Nam)

STT

H v tn

M s

Ngy sinh

Cp bc, chc v, chc danh ngh, iu kin, ni lm vic 6

1 2 I Tng I.1 Lao ng

Mc ng c Ph cp Tin TN TN lng CV VK ngh (%) (%) 7 8 9 10

Mc ng mi Ph cp Tin TN TN lng CV VK ngh (%) (%) 11 12 13 14

T thng, nm 15

n c Khng thng, s tr th nm BHXH 16 17 18

I.2 Mc ng

Cng tng

II Gim II.1 Lao ng

II.2 Mc ng

Cng gim

Phn CQBHXH ghi:

Phn n v ghi:

Tng s t khai: Tng s S BHXH ngh cp: Tng s th BHYT ngh cp: Cn b thu

.., ngy .thng..nm.

Ngi lp biu Thi hn t: n Cn b s, th

Th trng n v

ANH SCH LAO NG THAM GIA BHXH, BHYT

S: thng .. nm ...
Mu D02-TS (Ban hnh km theo Q s: 1111/Q-BHXH ngy 25/10/2011 ca BHXH Vit Nam)

Ghi ch

19

.., ngy .thng..nm.

Th trng n v

Tn n v/.L:Cng ty TNHH Thp DONGBANG Vit Nam M n v/.L: in thoi lin h: 03203.570.445~7
i tng tham gia: Ngi nc ngoi
STT H v tn M s Ngy sinh N a ch

DANH SCH NGI CH THAM GIA BHYT

S: thng 4.. nm 2012...

(Ban hnh km theo Q ngy 25/10/2011 ca

Lng ti thiu chung:

Ni ng k KCB ban u Quyn S CMT li 8 9 Bin lai S 10 Ngy 11 C 12 Mc ng Mi 13

T l NS h tr
T l ng (%) 14 Thi hn s dng th T ngy 15

1 I Tng

KIM JANG KIL

24/6/1960

Cty TNHH Thp DongBang Vit Bnh vin a khoa Tnh Hi Nam Dng

16,600,000

04/2012

Cng tng II Gim

Cng gim

Phn CQBHXH ghi:

Phn n v ghi:

Tng s th BHYT ngh cp:

Thi hn t:

Hi Dng, ngy 17 th

Cn b thu

Cn b s, th

V Q.L/i

SCH NGI CH THAM GIA BHYT

Mu D03-TS (Ban hnh km theo Q s: 1111/Q-BHXH ngy 25/10/2011 ca BHXH Vit Nam)

Thi hn s dng th S tin ng S thng 16 17 18 Ghi ch

Phn n v ghi:

Hi Dng, ngy 17 thng 4 nm 2012

V Q.L/i din .l

Tn n v/.L: M n v/.L: in thoi lin h:

DANH SCH IU CHNH MC NG CHO NGI CH THAM GIA BHYT

S: thng .. nm ...
Mu D04-TS (Ban hnh km theo Q s: 1111/Q-BHXH ngy 25/10/2011 ca BHXH Vit Nam)

STT 1 I 1 2

H v tn 2 Tng

M s 3

Ngy sinh 4

N C 5 6

Mc ng Mi 7

S thng 8

S tin ng 9

Ghi ch 10

Cng tng II 1 2 3 Cng gim ..,ngy..thng..nm n v qun l/i din i l Gim

Ngi lp biu

Tn i l: M i l: in thoi lin h:

DANH SCH NGI THAM GIA BO HIM X HI T NGUYN

S: thng .. nm ...
Bin lai T l Thu nhp lm cn ng c ng (%) 8 9

Mu D05-TS (Ban hnh km theo Q s: 1111/Q-BHXH ngy 25/10/2011 ca BHXH Vit Nam)
S thng ng

STT

H v tn

M s

Ngy sinh

N S Ngy 7

T thng

S tin ng

Ghi ch

1 A I Tng Tng mi

10

11

12

13

II

ng tip

III

ng li

Cng

.., ngy .thng..nm. i l

DANH SCH NGH THAY I THNG TIN CA NGI THAM GIA KHNG THAY I MC NG Thng.nm Mu D07-TS M s:.......................... Tn n v:..................................................................................... (Ban hnh km theo Q s: 1111/Q-BHXH a ch:................. ngy 25/10/2011 ca BHXH Vit Nam ST T 1 H v tn 2 Ngy sinh 3 N 4 M s 5 T thng, nm n thng, nm 6 7 Ni dung ngh 8 Ghi ch 9

ngh c quan Bo him x hi xem xt, gii quyt theo quy nh. Ngi lp biu .,ngythng.nm. Gim c