The Childbirth and Childcare Lump-Sum Grant additional benefits
for Insured Person or Family Member
System of receipt of the Childbirth and Childcare Lump-sum Grant directly by the medical institutions on your behalf
Information on insured person

Code
Insurance cardcode and number●●ケンポ

Furigana

Telephone number (ext.)

03-1234-5678(999)タロウ●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo〒123-4567
XXXX Condominium, #456

Address

XXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department

XXXX

Name

1-2-3 XXXX-cho, XXXX Ward, Tokyo
XXXX＠XXXX.ne.jp

E-mail address

Person expected to give birth(circle the applicable person）

Application details

NumberInsured person / Family member (dependent)

Name of person
expected to give birth

Hanako Kempo●● (Y) ●● (M) ●● (D) Date of birth for person

Due date and expected
number of babies

Single birth

Name of medical facility
institution where delivery is
expected

Multiple birth (babies)

XXXX Maternity Clinic●● (Y) ●● (M) ●● (D)expected to give birth
Address of medical facility
institution where delivery is
expected3-3-3 XXXX-cho, Yokohama City,
Kanagawa Prefecture■ Complete the following section if applicable

Insured person

1. If the insured person gave birth within six months after retirement→

Telephone number

Name, code and number, etc., of the insured person who is currently enrolled( )2. Childbirth and childcare by dependent within 6 months after qualification→
Name, code and number, etc., of the insured person who was previously enrolled–Code-number

Information ontransfer

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

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Bank

Central branch

Section to be filled out by the proxy to receive payment

Remarks

Please fill in the section for the authorization letter, except for persons enrolled in
Name of financial institution
Shinkin bankBranch number

BranchName of account
Savings account
Other
Account number
holderType of account If you
are a personinChecking
account enrolled() voluntary and continuous health insurance coverage or a(Katakana)(credit treasury)coverage and retirees.
voluntary and continuous health insurance

retiree, please fill in the section for information on transfer destination.

■ The Claim form will be accepted from two months before the expected date of delivery.

■ Please attach a copy of the part of the Maternal and Child Health Handbook that shows the expected date of birth or a document certifying the expected date of birth.
The applicant () (hereinafter, “Party A”) hereby designates the medical institution () (hereinafter, “Party B”) as its proxy and delegates the following authority to Party B.
Furthermore, Party A shall not make use of the system of direct payment of the Childbirth and Childcare and Childcare Lump-sum Allowance, etc., to medical institutions. Of the Childbirth and Childcareand Childcare Lump-sum Allowance, etc., claimed by Party A, this is related to the receipt of costs* related to Childbirth and Childcare charged to Party A by Party B.
* The upper limit shall be the amount of the Childbirth and Childcare and Childcare Lump-sum Allowance to be paid (includes the amount equivalent to additional benefits in the case that the insured
person claims additional benefits related to the Childbirth and Childcare and Childcare Lump-sum Allowance).

(Y)

(M)

(D)

Party A (insured person)

Address

Please ask the medical institution
to complete thisNamesection.
Party B (Medical institution,Address
Name

Financial institution for payment to proxy
Name of financial
institution
Account numberBank
Shinkin bank(credit treasury)

Savings accountCentral branch

BranchType of account

Other ()

Checking accountName ofaccount holder(Katakana)Remarks

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.

Date request received(stamp)

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 Society(20210401)