Applicant information

Claim for Health Insurance Payment of Funeral Expenses (Costs)
for Insured Person or Family Member
Insurance cardcode and number

CodeNumber●●XXXX

Name of affiliated
XXXX Co., Ltd., XXXX Branch
office/department Telephone number (ext.) 03-1234-5678(999）
Applicant date ofbirth

Name of applicant

Hanako Kempo〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456
(daytime phone number)
Employee ID
number

1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

1234567● (Y) ● (M) ● (D)Date of death●● (Y) ●● (M) ●● (D)XXXX＠XXXX.ne.jp

E-mail address

Cause of deathWas it caused by theactions of a third party?

Acute heart failure

Yes / No■ For application submitted upon the death of a family member (a dependent)
Relationship

Name of family
memberDate of birth(Y)

Application details(D) with the insured
personIf you fall under one of the following categories, please enter the name of his/her past insurer, and the health insurance code and number.
(1) Died within 3 months after being qualified as a dependent by this health insurance society(2) Died while continuing to receive the injury/illness allowance or maternity allowance after being disqualified from this health insurance
society to which he/she was previously enrolled(3) Died within 3 months after the end of receiving (2) after being disqualified from the health insurance to which he/she was previouslyenrolled

Name ofinsurer

Phone number()Code andnumber■ For application submitted upon the death of the insured person
Name of insured
personPersonal relationship between
the insured person andapplicantTaro Kempo

Date offuneralWife

BurialexpensesIf you fall under one of the following categories, please enter name of the insurer and the code and number of the health insurance in which
the deceased had been enrolled after retirement.
(1) Died within 3 months after being disqualified from this health insurance due to retirement, etc.
(2) Died while continuing to receive the injury/illness allowance or maternity allowance from this health insurance society after being
disqualified(3) Died within 3 months after the end of receiving (2) after being disqualified

Column to be certified by
the business owner(M)

Name ofthe deceasedyenName ofinsurer

Phone number()Code andnumber

Insured person or dependent

Date of death

Please ask your employer
for/ Dependenta certificate for
Insured person
H / R this(Y)section.
(M)(D)
Ifthatyou
cannotreceivea certificate, please Reiwa
attach documents
I hereby certify
the aboveis true andcorrect.
(Y)
(M)
(D)
which prove that death occurred (death certificate, burial
Office address
Name of officepermit, etc.).
Name of employer

Telephone number()

Remarks

Information on transfer
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

Hanako KenpoBank〇〇〇

Shinkin bank(credit treasury)

Savings accountType of accountChecking account

Other(Date: ● (Y) ●● (M) ●● (D))

Account
number〇〇〇Central branch

Branch0123456

Name ofaccount holder

Branchnumber123

Hanako Kempo(Katakana)

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.
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

Section to be completed by the labor and social security attorney submitting the application on behalf of the insured

Works Human Intelligence Health Insurance Society

Date request received (stamp)(20210401)

Applicant information

Claim for Health Insurance Payment of Funeral Expenses (Costs)
for Insured Person or Family Member
Insurance cardcode and numberCodeNumber●●XXXXName of affiliated
XXXX Co., Ltd., XXXX Branch
office/department Telephone number (ext.) 03-1234-5678(999）
Applicant date ofbirth

Name of applicant

Taro Kempo〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456
(daytime phone number)
Employee ID
number1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

1234567● (Y) ● (M) ● (D)Date of death●● (Y) ●● (M) ●● (D)XXXX＠XXXX.ne.jp

E-mail address

Cause of deathWas it caused by theactions of a third party?

Acute heart failure

Yes / No■ For application submitted upon the death of a family member (a dependent)
Relationship

Name of familymember

Hanako Kempo● (Y) ● (M) ● (D) with the insured

Date of birthApplication details

If you fall under one of the following categories, please enter the name of his/her past insurer, and the health insurance code and number.
(1) Died within 3 months after being qualified as a dependent by this health insurance society(2) Died while continuing to receive the injury/illness allowance or maternity allowance after being disqualified from this health insurance
society to which he/she was previously enrolled(3) Died within 3 months after the end of receiving (2) after being disqualified from the health insurance to which he/she was previously
enrolled

Name ofinsurer

Phone number()Code andnumber■ For application submitted upon the death of the insured person
Name of insured
personPersonal relationship between theinsured person and applicant

Date offuneralBurialexpensesIf you fall under one of the following categories, please enter name of the insurer and the code and number of the health insurance in which thedeceased had been enrolled after retirement.
(1) Died within 3 months after being disqualified from this health insurance due to retirement, etc.
(2) Died while continuing to receive the injury/illness allowance or maternity allowance from this health insurance society after being
disqualified(3) Died within 3 months after the end of receiving (2) after being disqualified

Column to be certified by
the business owner

Wife

personName ofthe deceasedyen
Name ofinsurer

Phone number()Code andnumberInsured person or dependent

Date of death

Please ask your employer
for/ Dependenta certificate for
Insured person
H / R this(Y)section.
(M)(D)
cannota certificate, please Reiwa
attach documents
I hereby certifyIfthatyou
the aboveis true andreceive
correct.
(Y)
(M)
(D)
Office address
which prove that death occurred (death certificate, burial
Name of officepermit, etc.).
Name of employer

Telephone number()

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

Remarks

Information on transfer
destination

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

Bank insurance coverage and retirees.Central branch
voluntary and continuous health
Shinkin bank(credit treasury)

BranchIf you are a person enrolled in voluntary and continuous health insurance
Savings
account

BranchnumberName ofcoverage or a retiree, please
fill in the section for information ontransfer
Account

Type of account
Other ( Checking

destination.

number)account

account holder(Katakana)

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.
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

Section to be completed by the labor and social security attorney submitting the application on behalf of the insured

Works Human Intelligence Health Insurance Society

Date request received (stamp)(20210401)