Dependent certification record
I hereby certify that the information listed below is true and correct. If there are any discrepancies with the facts, I do not object to the cancellation of certification or therefund of the benefits paid by the health insurance society. Also, if I obtain employment or if my income fluctuates, I will promptly engage in procedures for removing
dependents.

To the Executive Head of the Works Human Intelligence Health Insurance Society
Name of insured person
Date:■ Please enter the required information or circle the applicable items for the certified person.
Relat
Name of certified
Insurance
Num
Codeionscardberperson
hip(1)

Reason why application as adependent was madePlease list the health(2) insurance in which you are
currently enrolled(3) Are you currently working?
(4)

(5)

(6)

1. Obtained employment at company

2. Got married

4. Income decreased

5. Completed receipt of employment insurance benefits]

1. National Health Insurance 2. Health insurance provided by employer
3. Other health insurance/mutual aid association 4. Not enrolled*If you circled 1., 2., or 3. above, please enter the name of your health insurance society [YesNo

Were you enrolled in
employment insurance?

*If the basic daily amount exceeds
3,612 yen, certification is not possible(5,000 yen for those over 60 years old)(7)

Do you currently haveincome?

(8)

Please list your current
amount of income.

(Go to (7))(Go to (4))

Yes

No(Go to (5))(Go to (7))

Yes (Go to (6))

No (Go to (7))[Date of retirement: (Y)(M)

Please list the details of yourincome.

[Reason for retirement:]

1. Currently receiving pension
2. Currently applying or planning to apply [Date of procedures: (Y)

(M)

(D)]

3. Currently extending or planning to extend [Reason for extension
4. Completed receipt [Date of completion: (Y)5. Will not receive [Reason:(M)

]

(D)]

]

6. Other []YesNo(Go to (8))(Go to (10))[Annual income: approx.

(Go to (7))

yen] (Go to (9))
2. Real estate income
4. Self-employed income

A. Old age pension

B. Survivor’s pension

C. Personal pension

D. Disability pension

E. Corporate pension

F. Onkyu pension

G. Other []6. Social insurance benefits (please circle the type)
A. Injury and illness allowance

B. Maternity allowance

C. Work leave compensation, etc., from industrial accident compensation insurance

D. Other [7. Other [(10)](D)]

1. Salary (part-time income)3. Interest/dividend income
5. Pensions (please circle the type)(9)

3. Quit work and lost all income

6. Other [Did you work during the pastyear?

Please list the current statusof employment insurance
receipt.

AgeDo you live with the insuredperson?

]](Go to (10))

No
Yes

Reason for living separately []Amount transferred in one month [yen]*For details of attached documents, please check the documents list for other documents required for dependent certification.

■ If you want to certify a family member such as parents, parents-in-law, siblings (other than spouse/children living together), please
complete the following section.
No
Yes [Name of spouse:]
Does the certified person(11)1. Separation due to death 2. Divorce 3. Not yet
have a spouse?
[Annualincomeofspouse:yen]marriedRelationship
Does the certified person receive any aid?
NameAge Household Annual income■ Please fill in the family
Cohabit / Separateyen
Yes [yen] / No(12) structure of the certified
Cohabit / Separateyen
Yes [yen] / Noperson.
Cohabit / Separate

Works Human Intelligence Health Insurance Society

yen

Yes [yen] / No