6Required Documents Chart (２)Please check the chart below for thedocuments to be submitted and submit all
the applicable documents.

Start
Has the survey respondent enrolled in new health insurance due to employment, etc.?

NoY

Stream F

YesStream Dependent removal
procedures are required.

*1 P 9 - 8*2 P 8 - 3

P8-2

Resident Register Certificate (copy) for all members of the survey respondentʼs household(Certificate showing the family relationships)

1. If the survey respondent is a student, a Resident Register Certificate is not required if a copy of his/her student card or certificate ofenrollment is attached.
2. If the employee has taken up a post away from home and the survey respondent is living with the employeeʼs spouse/children, he/she shall be deemed to be “living together,” so please submit a Resident Register Certificate and a document verifying that theemployee has taken up a post away from home.

Living separately

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]✚P8- 1*1 P 9 - 8*2 P 8 - 3

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.)

RequiredDo the survey respondent and the policyholder (employee) live together
or separately? (If he/she is a student or has taken up a post away fromhome on company orders and is living together with the employeeʼsspouse/children, please go to "Living together.”)Stream GZ

Living together

P8- 1

1. If the survey respondent is a student, a Resident Register Certificate is not required if a copy of his/her student card or certificate ofenrollment is attached.
2. If the employee has taken up a post away from home and the survey respondent is living with the employeeʼs spouse/children, he/she shall be deemed to be “living together,” so please submit a Resident Register Certificate and a document verifying that the employee
has taken up a post away from home.

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

NoNoResident Register Certificate (copy) for all members of the survey respondentʼs household(Certificate showing the family relationships)

RequiredStream Dependent removal
procedures are required.

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

Obtainfrom
入手先
Obtainfrom
入手先2023 Income Certificate [copy]

Yes

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

Please submit the Response Form with the following documents attached.

All applicable documents

If the survey respondent is not aspouse or a child of the employee

Stream E

7Remittance Certificates [copy] for the last three consecutive months of remittances in 2023
(Please see the Nissan Kenpo website for the required remittance amounts.)

P9- 7
P9- 7

No

はYesいNoはYesいNo

StreamStreamStreamStreamStreamStreamX

EFGH

Z

Dependent removal
procedures are required.

If he/she has
pension income

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

Any oneof these✚

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.

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.)

Please reply to this survey by submitting the Response Form only,in the return envelope.
(After submitting the Response Form, please ensure you complete the dependent
removal procedures by November 20, 2023. The procedures are described onpage 10.)

（P8- 4

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

Stream X

Yes

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

Stream Y

Has the survey respondent
had any income since
January 2022?

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

Stream Z

Yes

All applicable documents

Is the policyholder sending remittances?
(Please see the Nissan Motor Health
Insurance Society website regarding thenecessary remittance amount[s].)Has the survey respondent
had any income since
January 2022?

Stream H

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

P9- 6

P9- 8Enclosed（