Applikazzjoni Gall-Karta ta l-Assikurazzjoni tasSaa ta l-Unjoni Ewropeja

Application form for the European Health Insurance Card

(EHIC)
Jekk jogbok imla bittri kbar / Please fill in using block letters.
EHIC gal applikanti minn sittax-il sena l fuq u enituri / EHIC for applicants aged sixteen and over, and parents

Isem
Name

Kunjom
Surname

Numru ta l-Identita
Identity Number

Tel / Mob

Data tat-Twelid
Date of Birth

e-mail *

Nazzjonalita`
Nationality
Indirizz
Postal Address

EHIC gal tfal tat is-sittax-il sena iddikjarati mill-enituri (jekk applikabbli)
EHIC requested for children (under 16) declared by parent (if applicable)
Numru ta l-Identita

ID Number

Kunjom
Surname

Isem
Name

Card gat-Tfal biss

EHIC for Child Only
Data tat-Twelid
Date of Birth

In-Numru ta l-Identita tat-tfal jinstab fil-passaport taghom jew fi-ertifikat tat-Twelid.

The ID Number of children may be found on their passport or birth certificate issued by the Public Registry.

Dikjarazzjoni / Declaration
Jien niddikkjara li l-persuni kollha imsemmija fdin l-applikazzjoni jgixu bmod permanenti fMalta jew Gawdex u
aettaw li jagtu d-dettalji personali taghom. Sa fejn naf jien l-informazzjoni kollha li niilt hija eatta.
I understand that all persons specified in this form live permanently in Malta or in Gozo and have consented to their personal
details being disclosed. All the information given on this form is correct and complete to the best of my knowledge.

___________________________________
Firma / Signature of Applicant

_____________________________
Data / Date

L-Entitlement Unit jibor l-informazzjoni sabiex ikun jista jagti servizzi mitluba skond ir-Regoli 1480/71 u 574/72 tal-Komunita Ewropeja. Kull informazzjoni
mibura u pproessata hija konformi ma l-Att dwar il-Protezzjoni tad-Data u l-Privatezza tad-Data, l-imsemmija Ordinanza u leislazzjoni sussidjarja ora.
The Entitlement Unit carries out its functions in accordance to EC Reg. 1480/71 and EC Reg. 574/72. All data is collected and processed in Accordance with the
Data Protection Act, 2001, the said Ordinance, other subsidiary legislation and the Privacy Policy of the Department.

23, St. John Street, Valletta, VLT 1168, Malta

Tel: 2299 2345
e-mail: entitlement.mhec@gov.mt
website: http://www.ehic@gov.mt

Jekk jogbok aqra sew:

Sakemm mhux immarkati basterisk (*), il-kaxxi jridu jimtlew KOLLHA. Applikazzjonijiet mhux
kompluti jew bdokumentazzjoni nieqsa ma jiux ipproessati. Fkaz ta` tigdid, il-card li tkun se
tiskadi ghandha tinbaghat mal-applikazzjoni biex tkun tista` tinhareg card gdida.
L-Applikazzjoni gandha tasal l-Entitlement Unit mill-inqas mistax-il urnata ta` xogol (15) qabel
id-data li fiha se ssiefer.
Applikanti bKarta ta l-Identita li tispia b(A) gandhom jehmu ma l-applikazzjoni prova li
jallsu l-kontribuzzjonijiet tas-Sigurta Sojali fMalta, jew prova li huma miewin lil ittadin
Malti, jew kopja tas-Certificate of Entitlement. Applikanti li gejjin minn pajjiz li mhux membru talUnjoni Ewroep
Persuni li gandhom E106, iridu japplikaw gall-EHIC mill-pajji fejn iallsu l-kontribuzzjonijiet
tas-Sigurta Sojali. Dawk li gandom E109 jew E121 gandhom japplikaw mill-pajji fejn jgixu.
Tfal tat is-sittax-il sena gandhom jitnilu fl-applikazzjoni mal-enituri.
L-Applikazzjonijiet gandhom jintbagtu lill-Kap ta l-Entitlement Unit, Ministeru gall-Politika
Sojali, (Saa, l-Anzjani u l-Kura fil-Komunita), 23 Triq San wann, Valletta VLT 1168.
Gal aktar informazzjoni jew fka ta diffikulta int mitlub li empel fuq 22992345, tibghatilna
email, izur il-website taghna jew inkella ur l-uffiju tagna fil-inijiet tal-ftu li jidhru hawn tat. Int
mitlub iib miegek il-Karta ta l-Identita.
Sajf

Xitwa

It-Tnejn, l-Erbga u l-imga

9:00 12:30

It-Tnejn u l-imga bejn 9:00 12:00

l-Erbga bejn 9:00 12:00 u 14:00 16:00

Please read very carefully:

Unless otherwise specified with an asterisk (*), ALL fields in the application form have to be duly
filled in. Incomplete applications or missing requested documentary evidence will not be processed.
In cases of renewal, the expiring card is to be returned with the application.
The application form should reach the Entitlement Unit at least fifteen (15) working days prior to the
departure date to allow for processing and postage of the card.
Applicants with an ID number ending in (A) should include with their application either proof of their
National Insurance Contributions or proof that they are married to a Maltese National or a copy of
their Certificate of Entitlement.
Those holding an E106 must acquire their EHIC from the country in which they pay their National
Insurance contributions. Those in possession of an E109 or E121 should apply for the EHIC from
their country of residence.
Children under sixteen years of age should be included in the application of one of their parents.
Applications may be sent to the Head of Entitlement Unit, Ministry for Social Policy, (Health, the
Elderly and Community Care), 23 St. John Street, Valletta VLT 1168.
For further information or in case of difficulty, you may phone on 22992345, send us an email, visit
our website http://www.ehic.gov.mt or visit our office during opening times shown hereunder. Make sure to
bring along your Identity Card.
Summer
Mondays, Wednesdays and Fridays
9:00 12:30

Winter
Mondays and Fridays between 9:00 12:00
Wednesdays between
9:00 12:00 and 14:00 16:00