2PLEASE READ THIS FIRST
Process up to Submission(1) Please check whether the survey respondents meet the eligibility criteria.
- Please read Certiﬁcation Criteria for Dependents on page 3 before conﬁrming
they meet the eligibility criteria.
- If a dependent does not meet the eligibility criteria, you must complete theseparate dependent removal procedures.
Please read Dependent Family Member Removal Procedures on page 10 before
completing the procedures to remove a dependent.

(2) Please ﬁll in the necessary information in the Response Form.
- Please check the information in the policyholder and survey respondentﬁelds in the attached Response Form and ﬁll in the necessary information.

Criteria for Dependent Certiﬁcation
Which family members may be recognized as “dependents”“The Society may recognize relatives as dependents if they are within the third degree ofrelationship from the policyholder (unlike “relative” under the Civil Code), and they must
mainly rely on the policyholder's income for their living expenses. For some relatives, there isan additional requirement that they live together with the policyholder."Requirement for residence in Japan“Having residence in Japan (having a Japanese residence certiﬁcate)” isa requirement that was added to the Health Insurance Act on April 1,2020 in regard to certiﬁcation of dependents.
Exceptions- Family members residing overseas and accompanying employees
posted overseas from Japan- Family members studying overseas from Japan
See the Nissan Motor Health Insurance Society website for details.

If the relationship of the survey respondent (to thepolicyholder) is spouse (wife or husband) or child- Please read the Required Documents Chart (1) on page 4 before preparing
the certiﬁcation documents listed for the stream that applies to the survey
respondent.

If the relationship of the survey respondent(to the policyholder) is not spouse or child- Please read the Required Documents Chart (2) on page 6 before preparing
the certiﬁcation documents listed for the stream that applies to the survey
respondent.

(4) Please submit the Response Form and the required documents.
- Please use the enclosed return envelope for submission.
- Please do not put any documents in the return envelope other than dependent
survey documents.
(Please submit a notiﬁcation of change of details and your insurance card to
the health insurance contact person at your workplace.)- Submitted documents cannot be returned, so please attach copies, asnecessary.
- Please note that you may be asked to submit additional documents after thedocuments you submit have been checked.

Great-grandparent
Uncle/aunt

Great-grandparent

Great-grandparent

Grandparent

Grandparent

Great-grandparent
Uncle/aunt

Deﬁnition of “living together”
If the policyholder and the dependent(s) are listed on the sameresidence certiﬁcate and live in the same residence, the Society
considers them to be “living together.”Great-grandparent
Uncle/aunt

Great-grandparent
SpouseGreat-grandparent
Uncle/aunt

Sibling

Nephew/niece

ParentParentSpousePolicyholder

Child

SpouseGrandchild

SpouseGreat-grandchild

SpouseSibling

SpouseNephew/niece

SpouseRelatives within the third
degree of relationship (chart)
Whether living together or separately(3) Please prepare the required documents (certiﬁcation documents) for all
survey respondents.

3

Living together is a requirement if not① 1st degree of relationship② 2nd degree of relationship③ 3rd degree of relationship

Note: “Spouse” includes de facto spouse.

Income criteria for relatives subject to certiﬁcation
According to oﬃcial notice from the Ministry of Health, Labour and Welfare, the following criteria(1) and (2) must be met.

(1) Income (Total payment amount Note: Includes commuting allowance, etc.)
Dependent's age, etc.

Annual income

Monthly amount (wages, pensions, etc.)

If under 60

Under 1,300,000 yenUnder 108,334 yen

If 60 or over

Under 1,800,000 yen

Under 150,000 yen

If receiving a disability pension

Under 1,800,000 yen

Under 150,000 yen

Please read Q.22 on page 12 if your income increased temporarily due to COVID-19 and it exceeded
the set criterion.

(2) Household relationship to policyholder, income, and allowances
If the dependent and the policyholder

The dependentʼs income is under half the policyholderʼs

If the dependent

The dependentʼs income is under half the policyholderʼsannual income and is under the amount of theallowance from the policyholder.

are living together

is living separatelyfrom the policyholder

annual income.

"If a dependent no longer meets the above certiﬁcation criteria for dependents, please read Dependent Family Member
Removal Procedures on page 10 before completing the procedures to remove that dependent family member.
Dependent removal procedures will also be required if the dependent has enrolled in health insurance at his/her place ofemployment.
If there is a delay in these procedures, the Society may make a claim for reimbursement of medical expenses, etc.
dating back to the date of removal."