The Childbirth and Childcare Lump-Sum Grant additional benefits
for Insured Person or Family Member
Information on insured person[If not using the system of direct payment to medical institutions, or if childbirth took place outside of Japan]
Code

Insurance cardcode and number

Name of affiliatedoffice/department

Name

Phone number

Date of birth

Address, telephone number,etc. of applicant(daytime phone number))(Y)

Phone number

Employee ID number

(M)

(D)

(Ext.

(M)

(D))

E-mail address
Name of person
who gave birthInsured person / Family member (dependent)

Delivery dateLive birth or stillbirth（circle the applicabletype）

(Ext.

〒

Person who gave birth(circle the applicableperson）

Application details

Number(Y)

(M)

(D)

Live birth / Stillbirth / Mixture of live birth and still birth

Name of born baby
Name of medical
institution
where baby was born

Date of birthof person who gave birth(Y)

Number of
Number ofBaby (ies) stillborn
live-bornbabiesbabiesRelationship between theinsured person and born
baby
Address of medical
institution
where baby was born

In the case of a stillbirth,the elapsed period ofpregnancy

Baby (ies)Is the born baby
a dependent?

(Weeks:) days
YesNo

■ Complete the following section if applicable

Insured person

1. If the insured person gave birth within six months after retirement→
Insurer’s name, code and number, etc., of the insured person who is currently enrolled
2. Childbirth by dependent within 6 months after qualification→
Name, code and number, etc., of the insured person who was previously enrolled

Telephone number( )–Code and number

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)

Name

Representative(individual actually receiving benefits)

Name

(Y)

(M)

Bank

Name of financial
institution
Type of account

Date:

Central branch

Shinkin bank(credit treasury)

Savings accountOther(Checking account)(D)

BranchName of accountholder

Account number

Branch number(Katakana)Physician / Midwife■ Certification section (please receive certification from one of the following)
Name of mother who gave
birth

Delivery date
Single birthMultiple birth (babies)

Number of babies born

Live birth or stillbirthLive birth

(Y)

(M)

(D)

Stillbirth (XXth month or XXth week of pregnancy)

I hereby certify that the above is true and correct
(Y)

(M)

Address of medical facility(D)

Name of medical facility

Municipal head

Name of physician or midwife
Registereddomicile

Name of head ofhousehold

Name of mother
Date of birth

Name of born baby

(M)

(D)

I hereby certify that the above is true and correct
(Y)

(M)

(D)
Name of municipal head

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

Remarks(Y)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.

Date request received(stamp)

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 passportDocuments forAttachment

1. Copy of agreement document with the medical institution, etc.
2. Copy of receipts issued by the medical institution, etc.
*If childbirth took place outside of Japan, please attach the following documents.
1. Certificate proving the birth 2. Japanese translation of the birth certificate 3. Copy of receipt
4. Copy of documents (passport, etc.) that show the period of overseas travel 5. Consent form for inquiries to overseas medical institutions, etc.

Works Human Intelligence Health Insurance Society(20210401)