Information on insured person

Injury and Sickness Benefits Application
CodeInsurance cardcode and number

NumberName of affiliatedoffice/department

Name

Phone number(Y)

Date of birth

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

Employee ID number

(D)

(Y)

(M)

(D)

(Y)

(M)

(D)

(Y)

(M)

(D)

)

E-mail address

Date of injury
or onset of illness

2)
3)

Was it caused by theactions of a third
party?

Cause of injury
or illness
Period taken off
due to injury/illness

Application details)(M)

(Ext.

1)
Name of injury /illness

(Ext.

(Y)

(M)

(D)

toDid you receive remuneration during the period taken off due toinjury/illness?
Will you receive remuneration in the future?

(Y)

(M)

Yes /No(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 of remuneration
receivedtoyen

(Y)

(M)

(D)

days

Amount of remunerationthat will be received■ Are you currently receiving or requesting disability pension/disability allowance, old-age pension,etc.?

yen
Currently receiving / Currently requesting /Neither

If you answered “Currently receiving” or “Currently requesting,” please complete the following section.
Type of pension, etc.

1. Disability pension 2. Disability allowance 3. Old-age pension 4. Other (Name of injury /illness)

Pension amountDate on which payment
Basic pension numbercommenced■ Are you currently receiving or requesting temporary disability compensation under Industrial Accident
Compensation Insurance?
If you answered “Yes,” please list the Labor Standards Inspection Office of the payee (entity to which request forcompensation was submitted).

(Y)
Yes /(M)(D)

No
Labor Standards
Inspection Office

Remarks

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 financialinstitution
Type of account

Savings accountChecking account

Other()

Date:

Bank

Central branch

Shinkin bank(credit treasury)

BranchAccount
number(Y)

(M)

(D)

Branch number
Name ofaccount holder(Katakana)

Individual number (not required when entering the code and number from the insured
person's card)

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 an opinion and certification from the attending physician.
Date of injuryor onset of illness

Name of patient

1)
Name of injury /illness

Date medical
treatment began

2)

Opinion of the attending physician

3)

(Y)

(M)

(D)

(Y)

(M)

(D)

(Y)

(M)

(D)

(Y)

(M)

(D)

Actual numberof days ofdays
medicaltreatment(D)

Cause of injury
or illness
Period during which
the inability to work
has been recognizedIf hospitalized, period ofthat hospitalization

(Y)

(M)

(D)

(Y)

(M)

(D)

(Y)

(M)

(D)

toto

(Y)

(M)

(D)

days

Main symptoms of injury/illness, progresssummary, treatment details, etc.
Medical opinion that recognized that work
carried out before then could no longer becarried out (based on course of symptoms)
I hereby certify that the above is true and correct.

Address of medicalinstitution

Date

Name of medical institution

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

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

DaysworkedPaidvacation(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(D)

(D)

(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

(D)

(D)

(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

(D)

(D)

Did you receive (will you receive) wages for the period listed
above?

Type of salary

Yes /No

Monthly salary

Daily salaryMonthly salary based on daily
accumulated salaryHourly wage

Percentage wage

Other ()

Payment period
Compensation paid
for the period above(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)

If no payment has been madeup to now and will not bemade in the future, state thereason
Method for calculation ofwages(deduction for absences, etc.)

I hereby certify that the above is true and correct. Office address
Date

Name of office
Name of employer[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