International Programs - Certificate of Coverage Request Forms

Certificate of Coverage Request Forms

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Click on the item you wish to see:

Your Personal Information	Your U.S. Location	Your Location in the Foreign Country
Name U.S. Social Security Number Foreign Social Security Number Date of Birth Country of Birth Country of Citizenship Country of Permanent Residence Married/Not Married? Employee's Address in the Foreign Country Date of Hire Country of Hire Beginning Date of Assignment Expected Ending Date of Assignment Private Health Insurance Employee's Family Members	American Employer or Foreign Affiliate? Employer's Company Name in the U.S. Employer's U.S. Street Address Employer's U.S. City Employer's U.S. State Employer's U.S. Zip Code	Employer's Company Name in the Foreign Country Employer's Foreign Street Address Employer's Foreign City Employer's Foreign Province or Country Employer's Foreign Postal Code Contact Person's Name Contact Person's Title Contact Person's Telephone Number Contact Person's Extension E-mail Address Mailing Address Is there anything else we need to know?

Your Personal Information

Name

In order to submit an electronic Certificate of Coverage Request, you must enter the employee’s:

First Name, you may include up to 15 characters.
Middle Initial, optional and can only contain 1 letter of the alphabet.
Maiden Name (Belgian, French, Italian, Luxembourg, Netherlands and Spanish Forms Only)--If a female employee's Last Name is
different from her Maiden Name, please enter the Maiden Name. You may include up to 20 characters.
Last Name is mandatory and may include up to 20 characters.

U.S. Social Security Number

This is a mandatory field. Enter the employee's Social Security number in 000-00-0000 format. Dashes, blanks, slashes and alphabets are not allowed.

Foreign Social Security Number (German, Italian, Norwegian and Spanish Forms Only)

If you know the employee's foreign Social Security number, please enter it. You may include up to 15 characters.

Date of Birth

This is a mandatory field.
Format:

Month of Birth and Day of Birth must each include one or two numeric characters: for example "3" and "31".
Enter the complete 4-digit year (e.g., 1954).

Country of Birth

This is a mandatory field and can include up to 20 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').

Country of Citizenship

Country of Citizenship is mandatory and can include up to 20 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').

Country of Permanent Residence

Country of Permanent Residence is mandatory and can include up to 20 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').
The employee's country of permanent residence is the country in which the employee has established a home intending to remain there permanently or for an indefinite period of time. Generally, a person will be considered to have established a home in a country if the person assumes certain economic burdens, such as the purchase of a dwelling or establishment of a business, and participates in the social and cultural activities of the community. If residence in a country is established, it may continue even though the person is temporarily absent from that country. Generally, an absence of 6 months or less will be considered temporary. If an absence is for more than 6 months, residence in the country will generally be considered to continue only if there is sufficient evidence to establish that the person intends to maintain the residence. Sufficient evidence would include the maintenance of a home or apartment in that country, the departure from the country with a reentry permit, or similar acts. The existence of business or family associations sufficient to warrant the person's return would also be considered.

Married/Not Married? (Belgian Form Only)

If the Employee is Married, click on the first Option. Click on the second Option if the employee is Single, Widowed, Divorced, or is no longer married for any other reason.

Employee's Address in the Foreign Country (Norwegian and Swedish Forms Only)

Please enter the Employee's Address in the Foreign Country, if known. You may use up to 30 characters in Blocks 1 and 2, and 20 characters for the foreign City.

Date of Hire

You must enter the Month, Day and Year of Hire.

Month and Day of Hire must include one or two numeric characters: for example "3" and "31".
Enter the complete 4-digit year (e.g., 1994).

Country of Hire

Country of Hire is mandatory and can include up to 20 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').

Beginning Date of Assignment

This is a mandatory field.
Format:
- Month of Assignment and Day of Assignment must each include one or two numeric characters: for example "3" and "31".
- Enter the complete 4-digit year (e.g., 1997).
The Beginning Date of Assignment cannot be earlier than the Date of Hire.

Expected Ending Date of Assignment

This is a mandatory field.
Format:
- Month and day the assignment is expected to end must each include one or two numeric characters: for example "3" and "31".
- Enter the complete 4-digit year (e.g., 2001).

Private Health Insurance (French Form Only)

You must click on the appropriate button to specify whether the employee and all family members accompanying the employee will have employer-provided or other private health insurance coverage while working in France. Under the U.S.-French Social Security Agreement, we cannot issue a Certificate of Coverage for a worker being sent to France unless such coverage is in effect.

Employee's Family Members (Netherlands, Norwegian and Swedish Forms Only)

Please enter the requested information regarding family members who are accompanying the employee on the overseas assignment. You may include up to 15 characters for each First Name, 20 characters for Maiden Name (Netherlands form only) and 20 characters for each Last Name.
Social Security Number (Norwegian Form Only)--If you know the family member's foreign Social Security number, please enter it. You may enter up to 15 characters.
Format for Family Member's Date of Birth (Netherlands and Norwegian Forms Only):
- Month of Birth and Day of Birth must each include one or two numeric characters: for example "3" and "31".
- Enter the complete 4-digit year (e.g., 1954).
If more than four children are accompanying the employee, use the Comment Box at the end of the Form to include information about the additional children.

American Employer or Foreign Affiliate?

The first Item under "Information About the Employer" seeks to determine whether the employee will be working in the foreign country for an American employer or for a foreign affiliate of an American employer.
If you are an American employer sending an employee to work on an overseas assignment directly for you (for example, in a branch office), check the first option.
If you are an American employer sending an employee to work on an overseas assignment at a foreign affiliate of your company, the employee may be working either directly for you or for the foreign affiliate. This is determined based on the "common-law control test." Under the common-law test, the employer is the entity that has the right to tell the employee what to do and how, when, and where to do it. The employer does not have to give these orders, but needs only the right to do so. You can find more information about the common-law control test in the Social Security Handbook.
- If the employee will be working directly for you (even though on the premises of the foreign affiliate), check the first option under this item.
- If the employee will be working for the foreign affiliate, we can issue a Certificate of Coverage for the employee only if you, as the American employer, have entered into an agreement with the IRS under section 3121(l) of the Internal Revenue Code to pay Social Security taxes for U.S. citizens and residents employed by the foreign affiliate. If you have entered into a §3121(l) agreement for this affiliate, you should have an IRS Form 2032 on file which shows the effective date of the agreement. If this is the case, check the second option under this Item, and give the date the §3121(l) agreement became effective.
- Format:

Your U.S. Location

Employer's Company Name in the U.S

Block 1 is mandatory and can include up to 60 characters.
Block 2 is optional and can include up to 40 characters.

Employer's U.S. Street Address

Block 1 is mandatory and can include up to 30 characters.
Block 2 is optional and can include up to 30 characters.

Employer's U.S. City

City is mandatory and can include up to 26 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').

Employer's U.S. State

State is mandatory and must match one of the U.S. Postal Service 2-letter State abbreviations.

Employer's U.S. Zip Code

A U.S. Zip Code is mandatory and must include numeric characters only. You may give either a 5- or 9-digit Zip Code.

Your Location in the Foreign Country

Employer's Company Name in the Foreign Country

Block 1 is mandatory and can include up to 60 characters.
Block 2 is optional and can include up to 40 characters.
If your company or an affiliate to which you are sending the employee operates in the foreign country under the same name you use in the United States, copy the name you entered under "Company Name used in the U.S."

Employer's Foreign Street Address

Block 1 may include up to 30 characters.
Block 2 may include up to 30 characters.

Employer's Foreign City

You must enter a foreign City. You can include up to 26 characters consisting of letters, spaces, hyphens (-), periods (.), commas (,) or apostrophes (').

Employer's Foreign Province or Country (Canadian and U.K. Forms Only)

If you are an employer sending an employee to Canada, you must enter the Province in your Canadian Address, including no more than 20 characters. If you are sending an employee to the United Kingdom, you must specify England, Scotland, Wales or Northern Ireland in the Country field of the Employer Address.

Employer's Foreign Postal Code

A foreign Postal Code should be entered, if known. No more than 12 characters may be entered.

Contact Person's Name

You must enter the name of a Company official or employee who can verify the information about the employer and employee. You can include up to 30 characters.

Contact Person's Title

If the contact person has an official company title, include it here. You can include up to 20 characters.

Contact Person's Telephone Number

You must enter the contact person's telephone number using numeric characters only. Include the 3-digit Area Code and a 7-digit telephone number.

Contact Person's Extension

If the Contact Person has a telephone extension that includes 4 digits or less, please include it.

E-mail Address

If you would like to receive an Internet E-mail notification when your request for a Certificate of Coverage has been approved, include the Internet E-mail address where you would like us to send the notification. The notification will be in the following format: "Certificate approved for control #_____. Thanks for using SSA's electronic Certificate of Coverage service." For security reasons, no other identifying information will be included, so be sure to save the Control Number you receive after submitting your Certificate Request. You should receive the actual Certificate of Coverage by regular mail soon after you receive the electronic notification.

Mailing Address

If your request for a Certificate of Coverage is approved and you would like the Certificate (or other correspondence) mailed to a U.S address other than the employer address you provided in the "YOUR U.S. LOCATION" section, please enter the name and address information requested. (For example, you might want a Certificate mailed to a different address if you are a central personnel office submitting a Certificate of Coverage request for a corporate office in another city or an accounting firm submitting a request on behalf of an employer client.) The Name of Person to Receive Correspondence may include up to 30 characters. Company Name, Street Address, City, State and ZIP must meet the same requirements that apply under the "YOUR U.S. LOCATION" section. If you make an entry for either Name of Person to Receive Correspondence or Company Name, you must also provide Street Address, City, State and ZIP.

If you do not enter any information in the "MAILING ADDRESS" section, we will use the address provided in the "YOUR U.S. LOCATION" section.

Is there anything else we need to know?

Use the Comment Box at the end of the Form to explain any special circumstances relating to your Request for a Certificate of Coverage. For example, tell us here if you are requesting an extension of a Certificate of Coverage we issued previously for the designated employee. Also use the Comment Box if you did not have enough space to complete your entry in any of the other data fields.