Application details

Information on insured person

Request for Payment of Maternity Allowance
CodeInsurance cardcode and number

NumberName of affiliatedoffice/department

NamePhone number(Ext.

Date of birth

Address, telephone
number, etc. of applicant(daytime phone number)

)
(Y)

(M)

(D)

〒
Phone number

Employee ID
number(Ext.

)

E-mail address

Due date(Y)

Period taken off
for childbirth

(Y)

(M)

(M)

(D)

Delivery dateto(Y)(D)

Did you receive remuneration during the period taken off due tochildbirth?
Will you receive remuneration in the future?

(Y)

(M)

(M)

(D)

(D)

days

To present

Have received / Have not received

In the futureWill be able to receive / Will not be able to receive■ If you answered “Have received” or “Will be able to receive” above, please enter the remuneration payment period and remuneration amount below.

Remuneration
payment period

(Y)

(M)

(D)

Amount ofremuneration
receivedtoyen

(Y)

(M)

(D)

days

Amount of
remuneration thatwill be received

yen

Certificate from physician ormidwife

Information ontransfer destination

Authorization Letter*If you wish to delegate receipt, please complete the authorization letter.
□(1) I hereby entrust the receipt of benefits based on this claim to the employer. ← Insert a check (☑) in the box of the applicable item.
□(2) I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)

Name

Name of financial
institution
Type of account

Savings accountChecking account

Other()Name of motherwho gave birth

Number ofbabies born

Bank

Central branch

Shinkin bank(credit treasury)

Branch(M)(D)

Name ofaccount holder(Katakana)(Y)

Live birth or Stillbirth(M)Live birth(D)

Date ofdelivery(Y)

(M)

(D)

Stillbirth (XXth month or XXth week of pregnancy)

I hereby certify that the above is true and correct.

(Y)

(M)

(D)

Address of medicalfacility
Name of medical facility
Name of physician ormidwife
Individual number (not required when entering the code and number from the insured person's card)

Remarks(Y)

Branch number

AccountnumberDue dateSingle birthMultiple birth (babies)

Date:Date request received (stamp)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.
One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number
card (both sides)
・When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Works Human Intelligence Health Insurance Society1

■ Please obtain a certificate from the employer.
Name of insured
personColumn to be certified by the business owner

Work status (use the following symbols: “〇” for days worked, “△” for paid vacation, “H” for national holidays, and“/” for absences)

Days
Paidworked vacation(Y)(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

Did you receive (will you receive) wages for the period
listed above?
Monthly salary
Daily salaryType of salary
Hourly wage
Percentage wage

Yes /No

Monthly salary based on daily
accumulated salary

Other ()

Payment periodCompensation paid
for the periodabove(salary, benefits,etc.)

Calculation ofwages

End ofpayment
periodDate ofpayment(D)□Applicablemonth(D)□Next month

Payment amount

Date of payment

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

If no payment has been madeup to now
and will not be made in thefuture, state the reason
Method for calculation ofwages(deduction for absences, etc.)

I hereby certify that the above is true and correct.

(Y)

(M)

(D)

Address

Employer

Name ofemployer
NameTelephone
number[To employers]● Please enter the working status, wage payment status, etc., for the wage calculation period, including the period when you did not work.
● You do not need to enter the work status if a copy of your attendance record is attached.
● Please attach a copy of your payroll book.

Works Human Intelligence Health Insurance Society2