Information on insured person

Request for Payment of Maternity Allowance
Insurance cardcode and number

Number●●XXXX

Name of affiliatedoffice/department

Name

XXXX Co., Ltd., XXXX Branch
Telephone number (ext.) 03-1234-5678（999）●● (Y) ●● (M) ●● (D)Date of birth

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)

Due date

Period taken offfor childbirthApplication details

Code

XXXX＠XXXX.ne.jp

E-mail address

●●(M)

●●(D)

● (Y) ●● (M) ●● (D)●●(M)● (Y) ●● (M) ●● (D)toDid you receive remuneration during the period taken off due tochildbirth?
Will you receive remuneration in the future?

●●(Y)

Delivery date

●●(D)

98

days

To present

Have received / Have not received

In the futureWill be able to receive / Will not be able to receive■ If you answered “Have received” or “Will be able to receive” above, please enter the remuneration payment period and remuneration amount below.

Remuneration
payment period

(Y)

(M)

(D)

Amount ofremuneration
received

toyen

(Y)

(M)

(D)

days

Amount ofremuneration thatwill be received

yenRemarks

Certificate from physician or
midwife

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)Date: ● (Y) ●● (M) ●● (D)Hanako Kempo

Name

RepresentativeName(individual actually receiving
Pleasebenefits)
fill in the section for the authorization letter, except for persons enrolled in
Name of financial
institution

voluntary and continuous healthBank
insurance coverage and retirees.

CentralbranchShinkin bankBranch number

Branch coverage or a
If you are a person enrolled involuntaryand continuous health insurance(credittreasury)

Name ofSavings account
OtherAccountaccount holder
Type of account retiree, please fill in the section for information on transfer destination.
)
numberChecking account ((Katakana)Name of motherwho gave birthDue date(Y)

(M)

(D)

Date ofdelivery

(Y)

(M)

(D)

PleaseLiveask
physicianmidwifebirththeor StillbirthLive birth orStillbirth(XXth month or XXth week of pregnancy)
for a certificate for this section
I hereby certify that the above is true and correct.
(Y)
(M)
(D)
Number ofbabies born

Single birthMultiple birth (babies)

Address of medical
facility
Name of medical
facility
Name of physician ormidwife
Individual number (not required when entering the code and number from the insured person'scard)*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

Works Human Intelligence Health Insurance Society

Date request received (stamp)1

■ Please obtain a certificate from the employer.
Name of insured
personPlease ask the employer for aWork status (use the following symbols: “〇”for days worked,“△”thisfor paidsection
vacation, “H” for national holidays,
certificate
forColumn to be certified by the business ownerand “/” for absences)

Days
Paid
worked vacation(Y)(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

(Y)

(M) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

days

days

Did you receive (will you receive) wages for the period
listed above?
Monthly salary
Daily salaryType of salary
Hourly wage
Percentage wage

Yes /NoCalculation ofwages

Monthly salary based ondaily accumulated salary

Other ()

Payment period
Compensation paid
for the periodabove(salary, benefits,etc.)

End ofpayment
periodDate ofpayment(D)□Applicablemonth(D)□Next month

Payment amount

Date of payment

(Y)

(M)

(D) to

(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to

(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to

(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen(M)(D)

If no payment has been madeup to now
and will not be made in thefuture, state the reason
Method for calculation ofwages(deduction for absences, etc.)

I hereby certify that the above is true and correct.

(Y)

(M)

(D)

Address

Employer

Name ofemployer
Name
Telephonenumber[To employers]● Please enter the working status, wage payment status, etc., for the wage calculation period, including the period when you did not work.
● You do not need to enter the work status if a copy of your attendance record is attached.
● Please attach a copy of your payroll book.

Works Human Intelligence Health Insurance Society2