Address of stay during a sick leave

This form allows the insured person to inform the CNS of an address of stay other than their legal address of residence.

An insured person is required to inform the CNS of their address of stay during an incapacity for work, if this address differs from the legal address of residence. Generally, the address of stay must be stated on the certificate of incapacity for work.

If the insured person has not provided the address of stay on the certificate of incapacity for work, they must inform the CNS for instance by using the form below.

IMPORTANT: Prior authorisation from the CNS is required for any stay during an incapacity for work in a country other than the one in which the insured person officially resides.

Authorisation for a stay abroad during an incapacity for work can only be granted in a limited number of situations.

This form cannot be used to apply for a stay abroad.

Fields marked with an asterisk (*) are mandatory.

Surname *

First name *

13-digit identification number *

Email *

Le format de date attendu comprend le jour (sur deux chiffres) suivi du mois (sur deux chiffres) suivi de l'année (sur quatre chiffres) : chacune de ces valeurs est séparée par un tiret.

Start date of incapacity for work *

Le format de date attendu comprend le jour (sur deux chiffres) suivi du mois (sur deux chiffres) suivi de l'année (sur quatre chiffres) : chacune de ces valeurs est séparée par un tiret.

End date of incapacity for work *

Address of stay (n° and street) *

Address of stay (postcode and town) *

Le format de date attendu comprend le jour (sur deux chiffres) suivi du mois (sur deux chiffres) suivi de l'année (sur quatre chiffres) : chacune de ces valeurs est séparée par un tiret.

Start date of the address of stay *

Le format de date attendu comprend le jour (sur deux chiffres) suivi du mois (sur deux chiffres) suivi de l'année (sur quatre chiffres) : chacune de ces valeurs est séparée par un tiret.

End date of the address of stay *

Name on the doorbell *

Tick the following box *

I have taken note that all correspondence will be sent to the official address and not to the address of stay and that the hours I am allowed to leave the house (10-12h and 14-18h) from the 6th day of incapacity remain applicable for the address of stay

* Mandatory field

Personal Data

To complete your application, the information about you collected from this form needs to be processed by the public administration concerned.

That information is kept by the administration in question for as long as it is required to achieve the purpose of the processing operation(s).

Your data will be shared with other public administrations that are necessary for the processing of your application. For details on which departments will have access to the data on this form, please contact the public administration you are filing your application with.

Under the terms of Regulation (EU) 2016/679 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, you have the right to access, rectify or, where applicable, remove any information relating to you. You are also entitled to withdraw your consent at any time.

Additionally, unless the processing of your personal data is compulsory, you may, with legitimate reasons, oppose the processing of such data.

If you wish to exercise these rights and/or obtain a record of the information held about you, please contact the administration in question using the contact details provided on the form. You are also entitled to file a claim with the National Commission for Data Protection (Commission nationale pour la protection des données), headquartered at 15, Boulevard du Jazz, L-4370 Belvaux.

By submitting your application, you agree that your personal data may be processed as part of the application process.