Column to be filled out by thehealth insurance society,000 yen (inthousands ofyen)Standard monthly
remuneration
Applicableclassification

Managingdirector

Issuance date:

Reiwa

(Y)

(M)

(D)

Effective date:

Reiwa

(Y)

(M)

(D)

Clericalsupervisor

Person in charge

Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form
*In order to pay the out-of-pocket limit at the counter, you need to apply to the health insurance society in advance and show your certificate before paying the medical expenses
at the counter.
*The issuance date of the certificate is set as the first day of the month to which the application date (date of receipt by the Health Insurance Society) belongs. Please consult with(Y)Current status of insured person

Insurance cardcode andnumber
Name ofinsured person

100

Code

Current status of applicable person

0

XXXX Department XXXX Section
151–Telephone
number:03(Telephone
number:03( ○○○○ )

○○○○

○○○○)

0051

X-X-X Sendagaya, Shibuya-ku, Tokyo

ケンポ

Furigana

イチロウ

Ichiro Kempo
Postalcode

Relationshipwiththe insuredperson

EldestsonShowa
HeiseiReiwa

Date of birth

○○○○
(Y)

(M)

1 0 0 1(D)01–

Please write “same as above” if the addressis the same as theinsured person
Telephone(number:Usage✔
□ Hospitalization care costs

Expected period ofhospitalizationor outpatient careReiwa ○○For urgent cases→(Y))

Outpatient care costs (including the dispensing of□ prescriptions)○(M) ○(D)to Reiwa ○○(Y)

Request receipt by around _________________(date)□✔ Address of the insured person

○(M)

○(D)

*It may not be possible to meet your request depending on the transport conditions.

□ Address of the eligible person□ Other [Home / Hospital] *Please enter any necessary names (addressee/care of), room numbers, etc.
Postal code–

If you selected “Other,” please write the desired
address for sending.
Please complete this section if the application is “toWas the injury caused by the actions of a third party (traffic accident, etc.)?
receive medical treatment for injury.”⇒ Yes /No

Individual number (not required when entering the code and number from the insured person's card)

Remarks

7xxxxx Co., Ltd.

Address of theinsured person

Desired destination
for sending theceiling-amountcertificate

5 3 0 6タロウ

Taro Kempo

Postalcode

Address ofapplicable
personケンポ

Furigana(D)

Date of birth
HeiseiName ofaffiliatedcompany
Name ofaffiliateddepartment

Name ofapplicable
person○○○○○Number(M)

Showa*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

A request is hereby made as detailed above for the issuance of an Eligibility Certificate for Ceiling-Amount.

To the Executive Head of the Works Human Intelligence Health Insurance Society
Labor and social security attorney submitting the application on behalf of the insured

Date of submission:
Date request received (stamp)