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Eie-/oppl ringspenger Omsorgspenger 1 Personlige opplysninger om arbeidstakeren 1.1 Etternavn, fornavn Opplysningene gjelder (kryss av) 1.4 Sykepenger 1.5 Sykepenger til til arbeidstaker sj mann 1.2 Bokommune 1.6 Foreldrepenger 1.7 Svangerved f dsel og adopsjon skapspenger 1.3 F dselsnummer (11 siffer) 1.8 Omsorgs penger 1.9 Pleie-/ 1.10 Annet: oppl ringspenger 1.11 N r startet arbeidsforholdet? (dd.mm. ) 1.12 Arbeidstakerens yrke/arbeid 1.13 Stillingsprosent % Ja Nei.

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