The form is filled in connection with requests for having health insurance expenses and sickness benefits refunded.
In order to have a refund, it must be documented that the seafarer is entitled to receive health insurance benefits. This documentation can, for example, consist in a copy of a Medical Report or an employment agreement. The Danish Maritime Authority must be furnished with the original bills.
Normally, refunds will be paid only if bills are forwarded that contain information about the insured person's name as well as information about the treatment, medicine, transportation, etc. offered. Normally, the bills forwarded must not be older than one year.
The expenses are divided into categories. If the bills belong to the same category, the total amount of expenses is given and the bills are stapled. A separate account showing how the shipowner has calculated the amount to be refunded will help us process the request.
In case of inconsistencies between the dates on the Medical Report and the bills, respectively, a reason for this inconsistency should be given.
The shipowners' associations recommend not to apply for a refund of expenses below DKK 1,000 per sickness or injury incident.
The form is used to refer the seafarer to a doctor, the hospital, etc. The first part of the form is filled in by the ship, the other part by the doctor and the last part can be filled in by the shipowner.
The form should be forwarded together with any request to have health insurance expenses refunded.
The form is to be filled in by the shipowner or any other employer when requesting sickness benefits or maternity/paternity benefits for seafarers abroad, including parental leave. The form can be signed in a Danish or English version.
The form, which is to be signed by the shipowner and the seafarer, is used both when requesting to have the shipowner's payment of sickness pay refunded - which is refunded in the form of sickness benefits - and when requesting to have sickness benefits paid directly to the seafarer.
Therefore, it is important that the shipowner forwards the form to the Danish Maritime Authority as soon as possible if the seafarer continues to be unfit for duty when the shipowner's obligation to pay sickness pay has stopped.