The Childbirth and Childcare Lump-Sum Grant additional benefits
for Insured Person or Family Member
Information on insured person[If not using the system of direct payment to medical institutions, or if childbirth took place outside of Japan]
Insurance cardcode and number

CodeNumber●●XXXX

Telephone number (ext.) 03-1234-5678(999）

ケンポ タロウ

FuriganaName●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo

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

Employee ID number1234567

E-mail address

XXXX＠XXXX.ne.jp

Person who gave birth(circle the applicableperson）

Insured person / Family member (dependent)

Name of person
who gave birth

Hanako Kempo●● (Y) ●● (M) ●● (D)Delivery date

Application details

XXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department

Live birth or stillbirth（circle the applicabletype）

Live birth / Stillbirth / Mixture of live birth and still birth

Name of born baby

Ichiro Kempo

Name of medicalinstitution
where baby was born

XXXX Maternity Clinic

Date of birthof person who gave birth●● (Y) ●● (M) ●● (D)Number of
Number ofcase of a stillbirth,
1 Baby stillborn Baby (ies) Inthetheelapsed
period oflive-born
weeks
pregnancy(ies) babies
babiesRelationship between theYes
Is the born baby
insured person and born
Eldest son
adependent?
NobabyAddress of medical
institution
3-3-3 XXXX-cho, Yokohama City, Kanagawa Prefecture
where baby was born

■ Complete the following section if applicable

Insured person

1. If the insured person gave birth within six months after retirement→
Insurer’s name, code and number, etc., of the insured person who is currently enrolled
2. Childbirth by dependent within 6 months after qualification→
Name, code and number, etc., of the insured person who was previously enrolled

Telephone number( )–Code and number

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)Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Name

RepresentativeName(individual actually receivingbenefits)
Pleasefill in the section for the authorization letter, except for persons enrolled involuntary and continuous health insurance
coverage and retirees.
Bank

Name of financial
institution

Central branch

Branch number

Shinkin bank(credit treasury)

If you are a person enrolled in voluntary and continuous health insurance Branch
Name of accountType of account

Savings accountcoverageor a retiree,Other
please fillin thesection for information on transferholder
Account
numberChecking account()(Katakana)destination.

Remarks

Municipal head

Physician / Midwife■ Certification section (please receive certification from one of the following)
Name of mother who
gave birth

Delivery date
Single birthMultiple birth (babies)

Number of babies born

Live birth or stillbirthLive birth(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 medical facility
Name of medical facility

Please ask the medical institution
oror municipal
head to certify this section.
Name of physician
midwife
Registereddomicile

Name of head ofhousehold

Name of born
baby

Name of mother
Date of birth

(Y)

(M)

(D)

I hereby certify that the above is true and correct
(Y)

(M)

(D)
Name of municipal head

Individual number (not required when entering the code and number from the insured person'scard)*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 passportDocuments forAttachment

1. Copy of agreement document with the medical institution, etc.
2. Copy of receipts issued by the medical institution, etc.
*If childbirth took place outside of Japan, please attach the following documents.
1. Certificate proving the birth 2. Japanese translation of the birth certificate 3. Copy of receipt
4. Copy of documents (passport, etc.) that show the period of overseas travel 5. Consent form for inquiries to overseas medical institutions, etc.

Works Human Intelligence Health Insurance Society(20210401)