Person in charge

Managing director Clerical supervisor

Health Insurance Notification of Change of Covered Dependents (Addition)

Section for insured
personSubmission
date:

(Y)

(M)

(D)

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

9. Reiwa

Code forinsurance card

Number for
insurance card

Section for dependent

Date ofbirth

5. Showa
7. Heisei

(Y)

(M)

(D) Standard
ｍonthly
remunera
tion

(Y)

(M)

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

Postal code

(Last name)(First name)

AddressName–Telephone number(Last name)Date ofbirth(First name)Name

5. Showa
7. Heisei
9. Reiwa

(Y)

–(M)

(D)
Gender 1. Male

2. FemaleIndividualnumberIncome(annualincome)Occupation

Relationship

Date ofbecoming adependent

7. Heisei
9. Reiwa(Y)

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

Address

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

ReasonRemarks(Furigana)

Section for dependent

7. Heisei
9. Reiwa(Furigana)(Furigana)(Last name)Date ofbirth(First name)Name5. 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)

Address

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

9. Reiwa

ReasonRemarks(Furigana)

Section for dependent

Acquisition
date:(Last name)Date ofbirth(First name)Name

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 study

Works Human Intelligence Health Insurance Society