Information on insured person

Injury and Sickness Benefits Application
Insurance cardcode and numberCodeNumber●●XXXX

Name of affiliatedoffice/department

Name

XXXX Co., Ltd., XXXX Branch
Telephone number (ext.) 03-1234-5678(999）●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo(daytime phone number)
Telephone number 03-7891-2345

1234567

Employee ID number1)
Name of injury /illness2)

XXXX＠XXXX.ne.jpE-mail address

Right thigh fracture
Date of injury
or onset of illness

Right istal radius fracture

●(Y)

●(M)

● (D)

●(Y)

●(M)

● (D)

(M)

(D)

3)
Cause of injury
or illness

Lost footing and fell down the stairs at home

Period taken off
due to injury/illness

Application details(Y)● (Y) ●● (M) ●● (D)toDid you receive remuneration during the period taken off due toinjury/illness?
Will you receive remuneration in the future?

Was it caused by theactions of a thirdparty?

Yes /● (Y) ●● (M) ●● (D)No

31daysTo 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

May 2, XXXX

Amount of remuneration
received

96,000toyen

May 10, XXXX

9days

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 /NeitherIf 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 amount

Date on which payment
Basic pension number
commenced■ 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*If you wish to delegate receipt, please complete the authorization letter.

Remarks

Information ontransfer destination

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)Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Name

Representative
Name for the authorization letter, except for persons
Pleasefill in the section(individual actually receivingbenefits)
Name of financial
institution

Type of accountenrolled in voluntary and continuous health insurance coverage andCentral branchBank

Shinkin bank(credit treasury)

retirees.

Branch number
BranchofSavings
account
If
you area personOther
enrolledAccountin voluntary and continuous healthName
insurance

Checking account()numberaccount holder(Katakana)coverage or a retiree, please fill in the section for information ontransfer

Individual number (not required when entering the code and number from the insured
destination.
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 injury
or onset of illness

(Y)

(M)

(D)

(Y)

(M)

(D)

Date medical
Please ask the attending physician
to complete(Y)treatment began
this section

(M)

(D)

(M)

(D)

Actual numberof days ofdays
medicaltreatment(D)

Name of patient

1)

Opinion of the attending physician

Name of injury /illness

2)

(Y)

3)
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)

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.

(D)

toto

(Y)

(M)

(D)

days

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)

Daysworked

Paidvacation

(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)

1Please2 3 4 5 6ask
7 8 9the10 11
12 13 14 15 for
16 17a18certificate
19 20 21 22 23for
24 25
26 27 28 29 30 31employer
this(D)(D)

Did you receive (will you receive) wages for the period listedabove?

sectionMonthly salaryYes /End ofpayment
periodNo

Monthly salary based on daily
accumulated salary

Daily salaryType of salary
Hourly wage

Percentage wage

Other (Date ofpayment)

Payment period
Compensation paid
for the period above(salary, benefits, etc.)

Calculation ofwages(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