Person in charge

Managing director Clerical supervisor

Insurance Card
Elderly Recipient Certificate
Insurance card Codecode andNumbernumber〇〇〇〇〇Showa
Date of birthHeisei(M)

Postalcode

Taro Kempo

Application Form(D)5 5 1 0 1 0

Taro Kempo

Name ofinsured person(Y)

Certificationacquisition dateHeisei
Reiwa

27(M)

1(D)

001

151-0051

X-X-X Sendagaya, Shibuya-ku, Tokyo
Address of theinsured person

xxxxx Co., Ltd.
XXXX Department XXXX Section

Reason for submission(Please circle the applicablereason)

Would you like to have thecard reissued?

1. Loss

Telephone number ０３(XXXX)XXXX(loss / theft / missing) Damage (including print that has rubbed off)

3. Other (1. Yes)

2. No

(Please circle the applicable answer)

1. For insured person
Furigana(1)

２． For dependent

Hanako Kempo

RelationshipApplicable person(Please circle the applicable item)

Hanako Kempo

Furigana
Complete this section if
the applicable person is (2)a dependent

Relationship

Section to be filled out by the insured person(Y)

100Furigana

Name of affiliatedcompany
Name of affiliateddepartment

Reissue due to
Loss or Damage

Relationship

Furigana(3)

Place where the card
was lost
Have you notified thepolice?

Wife(Y)(M)(D)

Date of birth

Showa
Heisei
Reiwa
Showa
Heisei
Reiwa

(Y)

(M)

(D)

Date of birth

(Y)

(M)

(D)

Date of birth

Showa
HeiseiReiwa

560921

1. Home 2. Other than home ( somewhere between JR Kinshichō Station and home ) → Police must be notified
Yes / No

Notification
destination

PoliceLost property No.
Kinshichō
Station notification
Date ofDate:

No.

1234

*Please describe in as much detail as possible

Circumstances underAt around 10:30 pm on Reiwa X (Y) XX (M) XX (D), I used a wallet containing my insurance card when exiting the ticket gate at the station closest
which the card was lost
to my home (JR Kinshichō Station). Afterwards, when I went shopping at a convenience store near my house at around 11:00 pm, I noticed that myor damaged
wallet was lost. I also lost the insurance card that was inside.
◎ If you are applying for reissuance due to damage to your health insurance card, please attach the damaged health insurance card to this application form.

Notification of Loss of Insurance Card / Elderly Recipient Certificate (complete this section only in the case of loss)
As stated above in the application, I lost my insurance card/elderly recipient certificate. I will be more careful when handling the card in the future.
If I find my insurance card/elderly recipient certificate, I will return it immediately.
I assume full responsibility for any accidents that may occur in my insurance benefits due to my loss of the insurance card, etc.

Date:Name of insured person

Taro Kempo
Date of submission:

To the Executive Head of the Works Human Intelligence Health Insurance Society

If your insurance card was lost or stolen, please immediately notify the health insurance society and police.
Also, we recommend using the Personal Declaration System* that is established by the personal credit information agency.
If the insurance card is fraudulently used by a third party, the health insurance society shall not assume any responsibility.
*Personal declaration system: A system in which information such as the loss or theft of a stolen ID card is registered with a personal credit
information agency. This enables the member companies of the credit agency to perform a more careful credit screening.
*For details on the procedures, etc., please directly contact the personal credit information agency.

Date request received (stamp)