TN N V

M n v:
a ch:

DANH SCH LAO NG THAM G

S

S
TT

H v tn

S s
BHXH

S th
BHYT

Ngy, thng,
nm sinh

N
(X)

S chng minh
th

Thng

TNG HP CHUNG
- S s BHXH c cp ............... s, T s: .................... n s:.................................
- S s BHYT c cp ............... th, Trong cp ngoi tnh:.....................................
- Thi hn s dng ca th BHYT: t ngy

n ngy:

Ngy thngnm..
Cn b thu BHXH

Ph trch thu BHXH

Mu s: 02a-TBH

AO NG THAM GIA BHXH, BHYT, BHTN

S

Thng

Nm 2009

Ni ng k KCB ban u
a ch

Ph cp

M Tnh

M Bnh vin

Tin lng, tin

cng

10

11

Chc
v
12

Thm Thm
Khu
nin nin
vc
VK ngh
13

14

15

ng
BH tht
nghip
(X)
16

NG HP CHUNG
Pht sinh tng

Bo him x hi

Bo him y t

1. S lao ng:
2. Qu lng tham gia
3. S phi ng:
4. iu chnh s phi ng
Ngy thngnm..
Ngi lp biu

Ngi s dng lao ng

Bo him tht nghip

ng t
thng, nm

Ghi ch

17

18

Bo him tht nghip

Tn c quan (n v) ........................
M n v:........................................
I LAO NG NGH HNG CH THAI SN
Thng ......... qu ........... nm
S hiu ti khon:....................................... m ti: ..................................................................
Tng s lao ng: ......................................Trong n: .........................................................
Tng qu lng trong (thng) qu:..........................................................................................

STT
A
I
1
...

II
1
...
III
1
...

IV
1
...

S s
H v tn BHXH
B
C
Khm
thai

iu
kin tnh
hng
D

S n v ngh
Tin
S ngy ngh
lng
tnh Thi gian
Ly k t
hng
ng
BHXH BHXH Trong k u nm S tin
1
2
3
4
5

Sy no
ht, thai
cht lu

Sinh con,
nui con

Thc
hin cc
bin
php
trnh thai

Tng
cng

Ngi lp

K ton trng

Th trng n v

S:.......................

Ghi ch
E

Ngy .... thng .... nm ....

Mu s: C67a-HD

M n v:

M KCB:

DANH SCH NGH IU CHNH H S CP S BHXH

(Km cng vn s ngy thng nm )

Tn n v:
a ch:

STT

H tn

S s BHXH

S th KCB

Ni dung thay i
(iu chnh)

Cn b thu

Ngy..... thng...... nm..........

Gim c BHXH

Mu s 03b-TBH

y thng nm )

Mi

L do iu chnh

NGH GIA HN TH BHYT:

- S th BHYT gia hn:.............. th; Trong ngoi tnh:............... th.

Thi hn s dng ca th BHYT t ngy __/__/____ n ngy __/__/____

Ngi lp biu

Ngy..... thng...... nm..........

Ngi s dng lao ng

DANH SCH I TNG THAM GIA

Tn n v:
M n v:
a ch:

Loi i tng:....................................................................
Thng..................... nm ............................

Ni .k KCB ban u
S
TT

H v tn

Ngy thng N
nm sinh (X)
3

S th BHYT
(nu c)

a ch

Tnh
7

I i tng tng

II i tng gim

* PHN TNG HP:

TT

Ch tiu

u k

Pht sinh trong k

Tng

Gim

Cuoi ky
6

- S i tng
- S tin phi ng BHYT
- S th BHYT c cp:.............. th; Trong cp ngoi tnh:............... th.

Cn b thu

Ngy..... thng...... nm..........

Ph trch thu

Ghi ch : Mu s 02b-TBH c quan qun l i t-ng c trch nhim lp gi c quan BHXH.

I TNG THAM GIA BHYT

Mu s: 02b-TBH
(Ban hnh km theo Q s: 1333/Q-BHXH
ngy 21/02/2008 ca BHXH VN)

..............................................................................

.................... nm ............................

Ni .k KCB ban u

Thi hn SD ca th BHYT

Bnh vin

Mc ng
BHYT

T thng
nm

n
thng
nm

Tng s
thng

10

11

12

S tin ng
BHYT

Ghi ch

13

14

Cuoi ky
6

Ngi lp biu

lp gi c quan BHXH.

Ngy..... thng...... nm..........

Th trng n v

M n v:

DANH SCH LAO NG THAM GIA V NGH CP S B

M KCB:

S:..........Thng........ Nm ..............

Tn n v:
a ch:

S
TT

H v tn

Ngy, thng, N
S s BHXH S th BHYT
nm sinh
(X)
3

S chng minh th
S

Ngy cp

M Tnh
cp

* Phn dnh cho c quan BHXH ghi:

- S s BHXH c cp:................................ s, T s:................................ n s:................................
- S th BHYT c cp:.............................. th, trong cp ngoi tnh:........................................ th.
- Thi hn s dng ca th BHYT: T ngy ____/____/_______ n ngy ____/____/_______
Ngy..... thng...... nm..........
Cn b tip nhn

Cn b QL thu

Ngy..... thng...... nm..........

Gim c BHXH

Phng php ghi:

* Mu s 01a-TBH do n v lp, khi n v mi tham gia BHXH, BHYT, BHTN ln u hoc khi c lao ng tng mi
(k c nhng ngi tham gia trc nhng ngng ng mt thi gian nay tham gia tr li) m cha c cp s BHXH h
- Ct 1, 2: ghi s TT, h tn ngi lao ng tng
- Ct 3: ghi s s BHXH ca ngi lao ng (nu c). Ngi lao ng c s ghi trc, cha c s BHXH ghi sau.
- Ct 4: ghi s th BHYT (nu c), cha c b sung sau khi c quan BHXH cp.
- Ct 5: ghi ngy thng nm sinh theo giy khai sinh
- Ct 6: nu l n nh du X
- Ct 7, 8: ghi s, ngy cp CMT ca ngi lao ng
(ni cp CMND c ly t ng t 2 k u ca s C
- Ct 9: ghi M tnh ca ni cp CMT theo M tnh cp th BHYT. Trng hp Tnh c tch hoc sp nhp th ghi theo n v hnh
Vd1: ni cp CMT l: CA TP. HCM th ghi m 79.
Vd2: ni cp CMT l: CA Tnh H Ty c th ghi m 01 (theo m H Ni).
- Ct 10: ghi nguyn qun theo giy khai sinh
- Ct 11: ghi chc danh cng vic.
- Ct 12: ghi a ch ni ng k thng tr (hoc ni ng k tm tr).
- Ct 13, 14: ghi ni ng k KCB ban u. M tnh v m bnh vin ni KCB (vd: TP H Ni = 01, TTYT Qun Ba nh = 059)
- Ct 15: ghi y s, ngy Q hoc HL; m i tng BHYT (nu l i tng c bit trong n v). Nu ngi lao ng lm
* Phn dnh cho c quan BHXH ghi:
- Ghi s s BHXH c cp t s n s.
- Ghi s lng th c cp trong k; trong ghi c th s lng th c cp ngoi tnh (nu c); thi hn s dng ca th.

 NGH CP S BHXH, TH BHYT

Mu s: 01a-TBH

Nm ..............

Nguyn qun

10

Chc danh
cng vic

a ch

11

12

Ngi lp biu

Ni ng k KCB
ban u (m s)
Tnh

Bnh vin

13

14

Ghi ch

Ngy..... thng...... nm..........

Ngi s dng lao ng

lao ng tng mi
cha c cp s BHXH hoc cp th BHYT.

BHXH ghi sau.

y t ng t 2 k u ca s CMND).
nhp th ghi theo n v hnh chnh cp Tnh, Thnh ph hin ti.

TYT Qun Ba nh = 059)

n v). Nu ngi lao ng lm ngh, cng vic nng nhc, c hi th ghi k hiu ch (A).

i hn s dng ca th.

15