Person in charge

Managing director Clerical supervisor

Health Insurance Notification of Change of Covered Dependents (Addition)

Section for dependent

Section for dependent

Section for insured
personSubmission
date:

(Y)

(M)

(D)

Section to be completed by the labor and social security attorney / health insurance society

0002 01

9. Reiwa

100Code for
insurance card

Number for
insurance card

ケンポ

(Furigana)〇〇〇〇〇

5. Showa
7. Heisei
Postalcode

Address

Kempo

Taro

ケンポ

ハナコ

Date ofbirthHanako

individualnumber(Furigana)(Last name)(First name)NameKempo
Wife

Date ofbecoming adependent

Occupation

Unemployed

Income(annualincome)(Y)

9. Reiwa

0,000 yen(in tens of thousandsof yen)(M)

(Last name)Date ofbecoming adependent

Occupation

University

Income(annualincome)ジロウ

Date ofbirth

Jiro

individualnumber(Y)

9. Reiwa

0,000 yen(in tens of thousandsof yen)(M)

Address(D)

000201

Reason(Last name)ｍonthly
remunera
tion

(Y)

(M)

,000 yen(In thousands of yen)(D)

501011

Remarks

123-4567

1-2-3 XXXX, XXXX Ward, Tokyo〇〇

5. Showa
7. Heisei
9. Reiwa–(Y)△△△△(M)

–□□□□

(D)

521222Retirement

ReasonName

Secondoldest(D) Standard

Gender 1. Male

2. Female

2. Living separately(First name)Kempo(M)

1. Cohabitation In the case of living separately Postal code(D)000201

ケンポ(Furigana)

Address(Y)

Telephone number

1. Cohabitation
2. Living separately

5. Showa
7. Heisei
9. Reiwa

Remarks

(Y)

Name

(D)
Gender 1. Male

2. Female

20500
1600 Pennsylvania Avenue, NW Washington, DCIn the case of living separately

Date ofbirth(First name)(M)*020601
Postal code

Foreign study(Furigana)

Section for dependent

Date ofbirth(First name)

Name

Relationship

7. Heisei
9. Reiwa

タロウ(Last name)

Relationship

Acquisition
date:

(1)

Remarks

5. Showa
7. Heisei
9. Reiwa

(Y)

(M)

*(D)
Gender 1. Male

2. Femaleindividualnumber
Income(annualincome)Occupation

Relationship

Date ofbecoming adependent(Y)

0,000 yen(in tens of thousandsof yen)(M)

9. Reiwa

Address

1. Cohabitation In the case of living separately Postal code
2. Living separately(D)ReasonRemarks**If there is no certificate of residence for the dependent in Japan, please check the requirements on the back and enter the applicable number in the remarks column.

Date request received (stamp)

Officeaddress

Postal code

Name ofoffice
Labor and social security attorney submitting the application on behalf of the insured

Name ofemployer
Telephonenumber（）Works Human Intelligence Health Insurance Society

*If there is no certificate of residence for the dependent in Japan, please check if any of the following requirements
apply to the dependent and enter the applicable number in the remarks column.
Number(1)Requirement

Students studying overseas

Person accompanying an insured person who is stationed forwork in a foreign country(2)[Specific example]
Person for whom a dependent visa is issued

Documents for Attachment

Copy of visa, student ID, enrollment certificate, admission
certificate, etc.

Copy of visa, letter of appointment for overseas assignment,
residence certificate issued by an overseas public institution, etc.

Person who temporarily travels abroad for sightseeing,
recreation, volunteer activities, or other purposes other thanemployment

(3)

(4)

(5)

[Specific examples]
In principle, a person whose visa has an expiration date; forexample, person who travels using the working holiday
system, family member who accompanies students studying
abroad, etc.
Person who has a personal relationship with the insured
person while the insured person is assigned to a foreigncountry and is recognized as equivalent to (2).

Copy of the visa, proof of the volunteer dispatching agency,
volunteer participation agreement, etc.

[Specific examples]
Copy of documents certifying birth, marriage, etc.
・ Child of insured person born during overseas assignment
・ Spouse who was married locally during an overseas
assignment
・ Specially-adopted child who was adopted during overseas
assignment
In addition to the persons listed in (1) to (4), persons who arerecognized as having their lifestyle based in Japan inconsideration of the purpose of travel and othercircumstances
Copy of documents certifying birth, marriage, etc.
[Specific example]
Children born while a dependent is living overseas for reasons
such as foreign studyWorks Human Intelligence Health Insurance Society