4

5Required Documents Chart (1)Start
Has the survey respondent enrolled in new health insurance due to employment, etc.?

No

Obtainfrom
入手先

Does he/she fall outside the Certification Criteria
for Dependents on page 3?

Stream Dependent removal
procedures are required.

Living separately

Has the survey respondent
had any income sinceJanuary 2022?

Is the policyholder sending remittances?
(Please see the Nissan Motor Health
Insurance Society website regarding thenecessary remittance amount[s].)StreamStreamStreamStreamStreamXＡＢＣDZ

If he/she haspension income

Most recent Pension Bank Transfer (Revised) Notice [copy]✚Any oneof theseP8- 4Wages/salary statements for the last three months [copies]

If he/she has had income
apart from employment or
pension since January 2022

P9- 5Complete set of 2022 tax return forms [copies]

Note: If a tax return was not filed, please submit documents confirming income and expenses.

2023 Income Certificate [copy]

P9- 6

P8- 2

Remittance Certificates (copies) for the last three consecutive months of remittances in 2023
(Please see the Nissan Kenpo website for the required remittance amounts.)

Remittance Certificates [copy] for the last three consecutive months of remittances in 2023
(Please see the Nissan Kenpo website for the required remittance amounts.)

Dependent removal
procedures are required.

Stream D

If he/she had
employment
income in 2022
(Jan. to Dec.)

Certificate of income and withholding tax for 2022 [copy]
2023 Income Certificate [copy]
Wages/salary statements for 2022 (all) [copies]

If he/she has
pension income

Most recent Pension Bank Transfer (Revised) Notice [copy]

Any oneof these✚

P9- 7
P9- 7

If he/she has had income
apart from employment orpension since January 2022

P9- 5Complete set of 2022 tax return forms [copies]

Note: If a tax return was not filed, please submit documents confirming income and expenses.

Please reply to this survey by submitting the Response Form only,in the return envelope.

（P8- 4

Wages/salary statements for the last three months [copies]

Stream X

NoStream

Certificate of income and withholding tax for 2022 [copy]
2023 Income Certificate [copy]
Wages/salary statements for 2022 (all) [copies]

Stream Y

はYesい

If he/she hademployment
income in 2022
(Jan. to Dec.)

Copy of student card or certificate of student status Document confirming nameand expiry date (If the expiry date of the student card is on the back, copies ofboth sides are required.)Stream Z

Has the survey respondent
had any income sinceJanuary 2022?

NoP8 - 1*P8 - 3
*P9 - 8

Together with the required documents listed above, please submit all the applicable documents listed below.

YesはYesいthat the person has taken up a post away from home or a copy of his/her student card or certificate of enrollment is attached.

Required

Living together

Stream CZ

Do the survey respondent and the policyholder (employee) live together
or separately? (If the survey respondent is a student or the policyholder
has taken up a post away from home on company orders, please go to"Living together.")*P8 - 3
*P9 - 8P8 - 2

Resident Register Certificate [copy] for all members of the survey respondentʼs household(Certificate showing the family relationships) Resident Register Certificate is not required if a certificate showing

All applicable documents

Stream Dependent removal
procedures are required.

NoP8 - 1

Together with the required documents listed above, please submit all the applicable documents listed below.

Stream B

Yes

Is the survey respondent a student
aged 22 or under (i.e., born on orafter April 2, 2001)?

No

2023 Income Certificate [copy]

YNo

Yes

the person has taken up a post away from home or a copy of his/her student card or certificate of enrollment is attached.

RequiredYes

Resident Register Certificate [copy] for all members of the survey respondentʼs household(Certificate showing the family relationships) Resident Register Certificate is not required if a certificate showing that

All applicable documents

is a spouse or a child of the employee

Please submit the Response Form with the following documents attached.

Stream A

Please check the chart below for thedocuments to be submitted and submit all
the applicable documents.

If the survey respondent(After submitting the Response Form, please ensure you complete the dependent
removal procedures by November 20, 2023. The procedures are described onpage 10.)

P9- 6

P9- 8

Enclosed（