The Childbirth and Childcare Lump-Sum Grant additional benefits
for Insured Person or Family Member
Information on insured person

System of receipt of the Childbirth and Childcare Lump-sum Grant directly by the medical institutions on your behalf
Code

Insurance cardcode and number

Name of affiliatedoffice/department

Furigana
Name

Date of birth

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

(Y)

(M)

(D)

(M)

(D)

〒
Phone number

(Ext.

)

E-mail address
Person expected to give birth(circle the applicable person）

Application details

NumberName of person
expected to give birthInsured person / Family member (dependent)(Y)

Due date and expected
number of babies

Single birth(M)(D) Date of birth for person

Multiple birth (babies)

Name of medical facility
institution where delivery isexpected(Y)

expected to give birth
Address of medical facility
institution where delivery isexpected■ 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

Section to be filled out by the proxy to receive payment

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 financial
institution

Savings accountType of accountChecking account

Other()

Date:

(Y)

(M)

(D)

Bank

Central branch

Shinkin bank(credit treasury)

BranchBranch number
Name of accountholder(Katakana)

Account number■ 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 Childcare andChildcare 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
Name

Party B (Medical institution,etc.)

AddressName

Financial institution for payment to proxy
Name of financial
institution
Account numberBank

Central branch

Shinkin bank(credit treasury)

BranchSavings accountType 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)