Comprehensive Insurance for Student Lives
Coupled with "Gakkensai" for International
Students/Incident Report Form

Please fill in the form using Japanese
if you are able to do so.

1. Please provide the details on the policyholder(1) Policyholder Number(2) Date of Birth(3) Name(spelling)(Kana)(4) Name of University(5) Student Number(6) E-mail Address@(7) Telephone Number(8) Document Mailing(In JapaneseYesNo)

Zip Code 〒Address

2. Please provide the details on the claim<When Claiming Medical Expenses>

If you have received treatment
for illness
If you have received treatment
for injury*The valid period shall continue until the last day of the month in which the 60th day following the first
medical examination falls.
In regard to the same injury or illness, this coverage is valid in the case that 180 days have passed fromthe last day<When Claiming Liability Insurance>

Comprehensive Insurance for Student Lives
Coupled with "Gakkensai" for International
Students/Incident Report Form

Please fill in the form using Japanese
if you are able to do so.

<For Illness Claims>(1) Provide us with the name listed on the health insurance card(2) Provide us with the name of the illnessYear(3) Provide us with the date you first visited the hospitalMonth□ Treatment complete(4)Were you hospitalized?
Do you plan to be hospitalized in the future?
(5) For which body part did you receive treatment?

Day□ Currently under treatment□ None □ Yes(From□ None □ Yes(Around)to□ Head □ Face □ Eyemonth later)□ Nose □ Ear□ Tooth□ Neck □ Shoulder □ Chest □ Stomach □ Back □ Hip□ Arm((6) What were the symptoms?

Right □ Left)□ Foot(□ Finger (Right □ Left)□ ToeRight □ Left)(□ Other(□ Fever□ ColdRight □ Left))□ Pain□ Other （)(Please answer the following questions)(7) Was this the first time you were treated for this illness? □ Yes(8) What was the number of points in the field titled “初再診” on
the receipt for your fist hospital visit?

(9) When did you begin receiving treatment?

□ 282 or moreFrom(10) Was there a period when you were fully recovered? □ Yes* This includes periods during which treatment was suspended.

Thank you for entering yourinformation.

ins-claim_chiryou@tmnf.jp□ No(Please answer questions (9) and (10))□ Less than 282 pointsyear(Frommonthdayto)□ No (receiving regular treatment)

Comprehensive Insurance for Student Lives
Coupled with "Gakkensai" for International
Students/Incident Report Form

Please fill in the form using Japanese
if you are able to do so.

<For Injury Claims>(1) Provide us with the name listed on the health insurance card

(2) Provide us with the name of the injury or illness

During the regularcurriculum/school event□ During travel to/from school□ During club activities□ Private (unrelated to school)□(3) What were you doing at the time of injury?

(4) What was the situation?

□ Collision□ Fall□ Cut□ Crushed□ Other ()MonthYear(5) Provide us with the date you first visited the hospital□ Treatment complete(Until(6) Were you hospitalized?
Do you plan to be hospitalized in the future?
(7) For which body part did you receive treatment?

Day□ Under treatment)□ None □ Yes(From□ None □ Yes(Around)to□ Head □ Face □ Eyemonth later)□ Nose □ Ear□ Tooth□ Neck □ Shoulder □ Chest □ Stomach □ Back □ Hip□ Arm□ Foot□ Other(Please tell us whether it was on the left or right side(8) What were the symptoms?

□ Finger□ Toe)

□ Left□ Cut□ Bruise□ Sprain□ Burn□ Right □ Unknown□

Brokenbone□ Dislocation□ Other ()(Please answer the following questions)(9) Was this the first time you were treated for your injury? □ Yes(10) What was the number of points in the field titled “初再診” on
the receipt for your fist hospital visit?

(11) When did you begin receiving treatment?

□ 282 or more
From(12) Was there a period when you were fully recovered? □ Yes* This includes periods during which treatment was suspended.

Thank you for entering yourinformation.

ins-claim_chiryou@tmnf.jp□ No(Please answer questions (7) and (8))□ Less than 282 points
year(Frommonthdayto)□ No (receiving regular treatment)

Comprehensive Insurance for Student Lives
Coupled with "Gakkensai" for International
Students/Incident Report Form

Please fill in the form using Japanese if youare able to do so.

<For Personal Liability Insurance>(1) Date/Time ofoccurrence

YearMonthDay
Phone(2) Contact for the Nameother party
Address(3) Future contact

Other( NameAbove(2)Insurance
Company(4) Type of accident

Approximate time：

Relationship(CompanyName）

RepresentativePhone)

Phone)

Water leaks going to lower floors
Property damage to other person's property
Other()

Traffic accident (please check the following)
BicycleWas the insured party
injured?
What was the otherparty’s vehicle?

Yes

Automobiles and motorcycles are NOT covered

Motorcycle

BicycleNoAutomobile

Was the other party injured?

PedestrianYes

Non-persons(fence, etc.)

NoPlease select the most similar type of accident.
1

Pedestrian

3

2

Other Party

Thank you for entering yourinformation.

ins-claim_baiseki@tmnf.jp

Insured Party

Insured Party

Other Party

Other A person who candescribe the situation
should do so below