English Translation

B B. Document e n. Dresben A1, Chancellery Class 1 1 (Postfließfach 29), Call 13435 Service and Service Center of the Member:hyi BM district No.: Application for the contribution of sickness costs (according to special tariff Sa KUB Saxon State official for all male workers over 18 years. Bindreichung felbf Res ol Jnye itwer Gigentum des Bereins über. 1. Name: Location: Street: Wt2 2. Does insurance against illness elsewhere; if yes, where? 3. Start of the disease: 2vet 945End: ...77945 aq 2a 4. Name of the illness: In the case of accidents: illness is based on an accident — Ia - No — description is included. ayca accident insurance is provided by the self employed: S00 uj ask Carifmäßige Dergütg: (will be completed by the Bez. Berw. Berficherungsdetändungen Referred sickness certificates:) 6. For doctor, incl. Dperations etc. RMr T R.M S uerveklamationen 7. , dental treatment . 2 8 8. " 3ahn treatment . . . 3 9. " professional nursing . . 4 10. , medicines . . 5 OS 11. Med. medicinal baths etc., electrical treatment, artificial high sun and similar remedies 6 according to § 14, paragraph 5 of the general dotftand beibilfeuche, 12. mineral waters (no table waters), minor remedies and pure liver tran 7 13. rupture bands and other bandages 8 14. eye glasses 6 15. Treatment etc. by healers . . . , . . 10 16. , Hospital- etc. Treatment ( .Cage per .. Ru) 11 12 ayí us 13 14 1gH 15 The documents submitted are issued 16 Deransgabe is not valid. To this end: Documents. ... Se.: RM s RM. S The accuracy of the above information is covered by compulsory insurance. , I ask for the transfer of the health contribution to my Ronto No. 3..17 ber. K to the current year or directly to the Gemeinbe-Girowege. Dresben, a194 am.. Bur Delegation: (Unteujchrift des Rntvagtellevs.) Statement by Bertrauensmann: Paid by Until when will the contributions be paid? Giro — Bank , am ..194... Post-Ab. -Scheck. Post-Bar-Scheck (Unterfchrift des Bertrauensmannes.) 20° 6 41 on ....