BAO HIEM XA HOI VIET NAM CONG HOA XA HOI CHU NGHIA VIET NAM Doc lap - Ty do - Hanh phic Miu s6: 01-TBH (Ban hanh kim theo CV s6 1615/BHXH- TO KHAI CSXH ngdy 02/6/2009 cia BHXH VN) HAM GIA BAO HIEM XA HOI, BAO HIEM Y TE, BAO HIEM THAT NGHIEP, Mas6: A. NGUOI LAO DONG: 1. Ho va ten: Nam Nit 2. Ngay théng nam sinh: __/__/ , Dan toc: » Quéc tich: 3. Nguyén quan: 4. Noi cur tra (Noi thudng tri hoc tam tri): 5. Ching minh thu sé: noi cap: ngay cfip:_/_/. 6. Hop déng lao dong (hoae hgp déng lam viéc): $6. ngiy___/ thing__/ nam cOhigulyc tirngay__/thang___/nam ___Loai hgp déng. 7. Chife vu, chite danh nghé: 8. Co quan, don vi: 9. Dia chi: 10. Noi dang ky kham chifa bénh ban dau: 11. Di tugng huding BHYT mite 12. Qué trinh dong, chua huéng BHXH mot lén va BH that nghiép: Cap bic, chife vu, che dan nghé, Phu of Set cmc ne, | ouiame at Le cu don vi, dia chi) = vu_| VK | nghe | SS 1 | 2 3 Os eres m | de {théng/nam|théng/nim| ! Cam két: Nhiing noi dung ké khai trén 1a hoan toan ding su thuc, néu sai toi xin chju trich nhiém trude php luat. _.ngay ..... thang Nguoi khai (K§ ghi ro ho ten) LdXAC NHAN NGUOI SU DUNG LAO DONG: Co quan, don vi, t6 chic. sau khi kiém tra, d6i chiéu hé so g6c ciia Ong (ba). x4c nhan céc noi dung ké khai trén 1A ding. ney MBAY voces RANG on. REM 202... Nguoi sit dung lao dong (K¥ va dong dain) C.XAC NHAN CUA CO QUAN BAO HIEM XA HO) Bao hiém xa hoi sau khi kiém tra, d6i chiéu v6i hé so gc ciia cA nhan Ong (ba) x4c nhan cdc noi dung ke khai trén 18 ding. sty MBQY coves thENG 0... nd 20.. Giém d6c BAXH (KS ghi r6 ho tén) (Kj va dong dau) C4n bo tham dinh Ghichi: = Miu O1-TBH do ngubi lao dong ke kh, lap 03 bin day di, trang chyc ede chi iew ign quan gi ngudi sit dung lao dong. 43