［ For foreign workers in Japan ］

英語版

Industrial Accident Compensation Insurance Application
Guidance for Foreign Workers＜Volume 2＞
General outline of Industrial Accident Compensation Insurance
Details of Various Insurance Benefits

Industrial Accident Compensation Insurance Act applies to foreigners who
work as employees in Japan regardless of nationality. Not only those who haveresident status which allows work but also foreign students who have part timejobs are also covered by Industrial Accident Compensation Insurance when they
get injured. This outlines Industrial Accident Compensation Insurance payments
and describes contents of the Benefits.
Feel free to contact nearby Labour Standards Inspection Office regarding any
further details such as the requirements for payment.
Please note that some kinds of the benefits can no longer be received after the
benefit claimant return home country.

【Table of contents】
Industrial Accident Compensation Insurance・・・・・・・・・・ P3
Medical (Compensation) Benefits・・・・・・・・・・・・・・・・・・・ P13
Temporary Absence from Work (Compensation) Benefits,
Injury and Disease (Compensation) Pension・・・・・・・・・・・ P15
Disability (Compensation) Benefits・・・・・・・・・・・・・・・・・・ P17
Surviving Family (Compensation) Benefits,
Funeral Expenses・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・ P25
Nursing Care (Compensation) Benefits・・・・・・・・・・・・・・・ P32
Examples・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・ P35

Ministry of Health Labour and Welfare, Labour Standards Bureau,
Industrial Accident Compensation Department, Compensation Division

Industrial Accident Compensation InsuranceThis insurance is a system which provides insurance benefits such as medical
expenses for workers who get injured, become ill or die due to work orcommuting. As long as they work in Japan, non-Japanese are also eligible forIndustrial Compensation Insurance.
【 Cause/Reason 】

other【 Disaster Type 】

Other
Accidents【Insurance】

HealthInsurance*Health insurance is not applicable for industrial accidents.

Types of Industrial Accident Compensation Insurance Benefits◆ Medical (Compensation) Benefits ： a worker who is injured or becomes ill due to work or commuting iseligible to receive this benefits for the medical treatment.
◆Temporary Absence from Work (Compensation) Benefits: a worker who is injured or becomes ill due towork or commuting and unable to work in order to receive treatment is eligible to receive this benefits forcompensation of wages.
◆Injury and Disease (Compensation) Pension: In case of not recovering from the injury or disease after 1
year and 6 months from the beginning of treatment and the severity of disability falls in certain physicaldisability certificate.
◆Disability (Compensation) Benefits: a worker who is injured or becomes ill due to work or commuting andthe disabilities remain is eligible to receive this benefits.
◆Surviving Family (Compensation) Benefits : when a worker died due to work or commuting , the bereaved
family is eligible to receive this benefits.
◆Funeral Rites Benefits: The benefits cover the deceased worker’s funeral expenses.
◆Nursing Care (Compensation) Benefits: The benefits cover the expenses of nursing care for recipients ofDisability (Compensation) Pension or Injury and Disease (Compensation) Pension.

2

【Definition of terms①】

When a worker suffers injury, disease, disability or death resulting from
employment-related cause, it is called Employment Injury.

work

injury/ disease
A certain level of
employment-relatedness●When injury / disease is employment-related, the term “employment ” is used.
● In principle, trainees and employers who are not workers, cannot receive the compensation.

◇ What is an Employment Injury?
To be approved as an employment injury, following 3 cases are
considered.
<1> Working in a building of workplace
If you are on duty in a building of workplace (office or factory) during
the regular working hours or overtime hours, the accident is approved
as employment injury unless the circumstances are exceptional.
*Following cases are not approved as an employment injury.
① A worker is involved in private activity during working hours
and suffers an accident② A worker intentionally causes an accident③ A worker is the victim of violence by a third party causedby personal enmity3<2> Not working in a building of workplace
If you are not at work during the break time or before or after working
hours and an accident happens because of your private action, it is not
approved as an employment injury.
However, if an accident happens because of the bad maintenance ofthe building or equipment in the workplace, the accident is an
employment injury. In addition, an accident happens duringphysiological phenomenon, such as using toilet, is considered as
an employment injury.
<3> Working outside of the workplace
Business trip or sales activity is approved as an employment injury
unless there are exceptional circumstances (for example, the worker
pursues to his/her private activity aggressively).

◇ What is an Employment-related Disease?
To be approved as an employment-related disease, following 3 cases
are considered in principle.
<1> Existence of adverse factor in the workplace
Harmful physical factor, chemical agent or the strain work withexcessive workload is in the duty (e.g. asbestos).
<2>Exposed to adverse factor which could cause health problem<3> The course of disease and clinical condition are reasonable fromthe medical perspective
If a worker contact with an adverse factor which exists in the working
activity, an industrial disease occurs as in the result of the contact. So
the symptoms must appear after the worker was exposed to theadverse factor. The timing of symptoms is different according to thenature of the adverse factor and contact condition.

4

【Definition of terms②】

When a worker suffers injury, disease, disability or death
resulting from commuting, it is called Commuting Injury.
◇What is “commuting”?
“Commuting” refers to the reasonable routes and methods used byworkers who travel to or from work noted in ① to ③ below.
① Travel back and forth between a worker’s residence and workplace(the place where workers start and finish work)② Travel between the work place where Ministry of Health, Labourand Welfare ordinance stipulates and another workplace(a worker with multiple jobs)③ For employee transferred without family, travel between theresidence in assignment location and the home

Commuting Form
1 General case

*Note) There are fixed requirements for Form 2 and 3Home

2 Multiple Jobs

Workplace

3 Assignment away from home
Other
workplace

Workplace

Workplace

Assignment
residence

Home

5

Home

◇Commuting Scope
If the worker deviates from the travel route or interrupts travelling, the time during thedeviation or interruption, and the travel thereafter is not treated as commuting.
However, in the event the minimum such deviation or interruption is necessary for daily
life, for example purchasing everyday items, the travel after returning to the normal routeis treated as commuting.

Commuting Scope○

Workplace○・・・ Items recognized as being within the scope of commuting
×・・・Items not recognized as being within the scope of commuting

×Interruption

×

×

×

Home

×

Deviation○
Workplace×*Same for travel froma workplace to anotherworkplace and from anassignment residence
to home.

×
Action is required fordaily life and designatedin Ministry of Health,Labour and Welfare
ordinances(Interruption)

×
Action is required fordaily life anddesignated in Ministryof Health,Labour and Welfare
ordinances (Deviation)

6

○
Home

×

◇ What is the basic daily benefits payment amount?
The basic daily benefits payment amount, in principle, should be an amountequivalent to the average wages specified in Article 12 of the Labour
Standards Law
Average wages, in principle, is the amount calculated by dividing the total amountof wages paid to the worker over the 3 months previous to the day on which theneed to calculate the amount arises* by the total number of days (the total numberof calendar days including weekends) in the period.
The wages which serve as the basis for calculating average wages refers to
payments paid by employer to workers regardless of the names or titles given to thosepayments. However, marriage allowance, other temporary wages, bonuses and otherwages which are paid only one time or paid once in more than 3 months are not calculated
for this amount.
* It means the day when the accident resulting in injury or death occurred or the
day on which a disease is diagnosed by a doctor. However if a wage calculation
cut-off date is specified, the cut-off day in previous month is the day on which theneed to calculate the amount arises○Exceptions① In the following situations where it is determined that it is not appropriate tocalculate the basic daily benefits payment amount from an amount equivalent
to average wages, a special calculation method for the basic daily benefits
payment amount can be used.
(a)If any work is missed during the average wages calculation period forreceiving treatment of non-work related injury or disease(b)If a pneumoconiosis patient is transferred to a non-dust related job(c)Other② As for the Temporary Absence from Work Benefits, the minimum or maximum
amounts based on the recipient’s age bracket can be applied after 1 year and 6
months have passed since the treatment began.
As for the Pension Benefits, the minimum or maximum amounts based on therecipient’s age bracket can be applied from the first month the pension is paid.

7

Basic daily benefits payment amount Calculation Examples(Example) The worker receives wages of 200,000 yen per month, with end ofmonth when the wage calculation closes. The accident occurs in October.
200,000 yen×3 months÷92 days (July (31 days)＋August (31 days)＋September(30 days)≒6,522 yen
6,522×80% ≒5,217yen→ 5,217 yen, 80% of the basic daily benefits amount is paid per day of lost work.
→ The above “wages” do not include temporarily paid wages or
wages paid once in more than 3 months.
“Wages paid once in more than 3 months such as bonuses” will be reflected
when Surviving Family Special Pension Amounts and others are determined.

◇ What is the basic daily calculation amount?
The basic daily calculation amount is, in principle, the amount calculatedby dividing the basic annual calculation amount, which consists of thetotal special payments received by a worker from a employer for 1 year
prior to the day, a work or commuting related accident resulting in injury
or death occurred, or the day on which an disease is diagnosed by a doctor,
by 365.
Special payments refers to bonuses and other wages paid once in morethan 3 months which are excluded from calculation of the basic daily
benefits payment amount. (Temporary wages, such as marriage allowance,
are not included)
If the total special payments exceed 20% of the basic annual benefits
amount (the amount equal to 365 times the basic daily benefits payment
amount), the amount equivalent to 20% of the basic annual benefits
amount will be used as the basic annual calculation amount.
(the limit is 1,500,000 yen)8【Approval condition about each disease ① 】

Brain and Heart Disorder“vascular brain disease” such as brain infarct and “cardiac disease” such as cardiac infarct areformed from vascular pathology due to heredity and a variety of daily lifestyle factors including
mainly increased age, diet and living environments, and these gradually develop and worsen until
suddenly manifesting. However, on occasion vascular pathology and other effects can worsen as
result of excessive work, leading to development of brain and heart disorders.
In the approval standards, if the onset of brain and hearth disorders can be *clearly proven to be a
result of excessive workload, they can be eligible for Industrial Accident Compensation.
* Excessive workload means the workload which is objectively admitted by the medical
experimental rule that it could significantly worsen vascular disease, which is the cause of brain
and heart disease, than the natural course of disease.
＜Subject disease＞○ Vascular brain disease・ Intracerebral bleeding（ Cerebral bleed ）・ Subarachnoid bleeding○Ischemic cardiac disease etc.
・ Stroke・ Hypertensive
encephalopathy

・ Cardiac
infarct・ Angina

・ Heart arrest (including sudden
cardiac death )・ Dissecting aortic aneurysm[Requirements for Industrial accident approval]
In the event of any of the following cases, it is approved as an industrial accident
Abnormal incidents
Encountering abnormal incidents from 1 day before up to immediately before theonset of symptoms.
This requirement is considered, for example, when the worker is directly involved in work related serious
fatal accident and the worker suffers significant mental load or significant physical load because theworker was involved in rescue effort or deal with accident

Excessive workload in a short period
Engaging in excessive amounts of work during a period close to the onset ofsymptoms.
(1) The duty from 1 day before up to immediately before the onset of symptoms is especially
excessive. (2) Even if the duty from 1 day before up to immediately before the onset of symptoms is
not approved as especially excessive duty, the disease is considered to be related with the symptoms If
excessive workload continues within about 1 week before the onset of symptoms

Excessive workload over a long period
Engaging in particularly excessive amounts of work leading to accumulated
fatigue for a long time before onset of symptoms.
In the case of more than 45 overtime hours per month, the symptoms are more associated with work.
(a) If over 100 hours of overtime work for 1 month before the onset of symptoms can be confirmed,(b) If over 80 hours of overtime work per month for 2 to 6 months before the onset of symptoms canbe confirmed, the symptoms will be considered to be closely associated with work
* In the case of excessive workload in a short period and a long period , working conditions (irregular
working hours, long hours on duty, many business trips, shift system and midnight shift), work environment(temperature, undesired sound and time lag) and mental stress as well as working hours are also supposed to
be examined.

9【 Approval condition about each disease ② 】

It is considered that mental disorder develops in the balance between thepsychological burden from the outside (stress) and response capabilities which candeal with the psychological load.
When strong psychological load* comes from the work and mental disorder develops,
it will be covered by Industrial Accident Compensation.
* psychological load is objectively considered that it potentially causes the subjected disease[Requirements for Industrial accident approval]
Industrial Accident compensation is approved when the following requirements are
all filled.

Mental disorder covered by the approval standard develops
Mental disorders which are classified in Chapter V of the 10th revised version of International Statistical
Classification of Diseases and Related Health Problems（ICD-10) “Mental and behavioral disorders”.
(Cognitive impairment and disorder resulting from head injury are not included)(e.g. depression, acute stress reaction)

Serious physiological burden caused by the duty during about 6
months before the onset of mental disorder is confirmed(e.g.) severe harassment, bullying, violence and incidents which could generate the change of contents ofwork or workload* In the case of some repeated actions, like bullying or sexual harassment, if it started more than 6 months
prior to the development of the disorder and continued until the development, the psychological burden isevaluated from the actions started.

The mental disorder is not resulting from psychological burden
outside work or individual factors
Private events (divorce, living away from the spouse) or events related to the family (death of spouse, child,parent, or sibling) are carefully judged if they are the cause of disease.
Presence and the contents of individual factors, such as history of mental disorder and alcoholism, areexamined and if they exist, they are carefully judged if they are the cause of disease.

10

【 Approval condition about each disease ③ 】

Excess use of arms and hands could cause inflammation of neck, shoulder, arm,
hand or finger or abnormality of joint or sinew.
Disorder of upper limbs means such inflammation and abnormality.
<typical diagnostic names>
・Lateral epicondylitis (medial epicondylitis)
・Cubital tunnel syndrome・Supinator (pronator teres )syndrome
・ Arthritis of the hand・ Tendon sheath inflammation ・ Carpal canal syndrome
・ Cheirospasm[Requirements for Industrial Accident approval]
Industrial Accident Compensation is approved when the following requirements
are all filled.

The symptoms develop after the engaging the work which put burden on
upper limbs* for long period (more than 6 months in principle)
The following tasks fall into the category① Task with frequent repeating motion of upper limbs② Task which is conducted with upper limbs upward③ Task which has the less movement of neck and shoulder and the posture is restricted④ Task which puts burden on particular body parts on upper limbs* upper limbs means back of the head, neck, scapular arch, upper arm, lower arm, hand, and finger.

Being involved in a heavy task before the onset of symptoms
In the case that a worker was involved in the task which put burden on upper limbs for 3 months
before the onset of symptoms in the following circumstances.
・In the case workload is almost stable
The worker was involved in the task which had workload by 10% or more for about 3
months compared with the similar task in which the same-sex and similar-age worker is involved
・ In the case workload is not stable① There was workload per day by 20 % or more than usual and the worker had such days about
10 days a month and such circumstance continued 3 months (If the total workload a month is notdifferent from the usual workload, it is included)② During about 1/3 working hours a day, the workload was over by 20 % or more than usual, andthe worker had such days about 10 days a month and such circumstance continued about 3
months (If the average workload a days is not different from the workload, it is included).
※ When judging if the worker was involved in heavy task, not only the workload but the following
conditions are also considered.
・ Long time work, continuous work ・ Excessive stress ・ Heteronomous and high work pace・ Unsuitable work environment ・ Excessive weight load, use of power

Engaging excessive workload and the course of the onset ofsymptoms are approved as medically reasonable ones11

【 Approval condition about each disease ④ 】

Backache
There are 2 types of backache which Industrial Accident Compensation covers andmedical treatment is necessary. Approval requirement is set for each type.
［ Requirements for Industrial Accident approval］

Backache resulting from accident
Backache caused by injury and fills the both requirement of ① and ②① Back injury, or sudden power caused the injury was generated by a sudden
accident during working.
② It is medically approved that the power worked on the back caused the
backache or significantly worsened the previous symptoms of backache orunderlying medical problem.

Backache not resulting from accident
The worker who handled heavy load and suffered excessive burden on the backhad the backache and it is approved that the work caused the ache judging fromthe condition and period of the work.
Backache not resulting from accident is divided into 2 types according to thecauses.
◇ Backache caused by muscle fatigue
Backache caused by muscle fatigue after being involved in the task in relatively
short period (about 3 month or more) is covered by Industrial Accident
Compensation.
• Task with handling heavy goods about 20 kg or more handling different in weight heavy goods• in a half-crouching position repeatedly• Task required maintaining an awkward position for the back for some hours every day• Task required limited movement (a worker cannot stand up for a long time and have to keep thesame position)• Task with receiving constant big shaking on the back

◇Backache caused by deformation of bone
Backache caused by the bone deformation resulting from the involvement in
the task handling heavy goods, including following, for a long time (about 10
years or more) is covered by Industrial Accident Compensation.
• Task handling heavy goods of about 30 kg or more for 1/3 working hours or more
• Task handling heavy goods of about 20 kg or more for 1/2 working hours or more
* Backache caused by bone deformation is approved to be covered by Industrial Accident
Compensation only when the deformation “obviously exceeds the normal change by aging”

12Medical(Compensation) Benefits
療養（補償）給付について
When a worker is injured or becomes ill as a result of work orcommuting and requires medical care, until the relevant injury or
disease is *”Cured”, the worker can receive Medical Compensation
Benefits (for employment injury) or Medical Treatment Benefits (forcommuting injury).

Benefit Details
Medical (Compensation) Benefits consist of “Medical Treatment Benefits” and“Treatment Expense Payment”.
●“Medical Benefits” are benefits in kind where care and medicine can be supplied freeof charge at Rosai (Industrial Accident Compensation) hospitals, designated medical
facilities and pharmacies, etc.(hereafter referred to as ”designated medical facilities”.
●“Treatment Expense Payments” are capital benefits where expenses incurred fortreatment are paid when a worker receives treatment at a medical facility or pharmacy,
etc. other than designated medical facilities because such facilities are not located closeby or other reasons.
The scope and period of medical treatment covered by the benefits are the same for both.
Medical (Compensation) Benefits include general items required for medical care including treatment
costs, (e.g.: treatment cost, hospitalization fees, transportation expenses, etc.)and are provided until
injuries or diseases are *cure or symptoms stabilized◇ What does “Cured” mean?
In Industrial Accident Compensation Insurance “cured” does not refer only to returning thevarious organs and tissues of the body to their original healthy state, but can also refer to astate where the symptoms of injuries and diseases are stabilized and where no further medical
effect can be expected(Note2)even if further generally recognized medical treatment isprovided (Note1), referring to a condition of “stabilized symptoms”.
As such, even in situations where some symptoms remain such as “situations where treatmentusing medical or physical therapy cannot be expected to provide more than temporary
recovery”, and if it is determined that no further medical effects can be expected, the situationis treated as “cured” (symptoms stabilized)for the view of Industrial Accident Compensation
Insurance, and further Medical (Compensation) Benefits will not be provided.
(Note1) “Generally recognized medical treatment” refers to treatment recognized within the scope ofIndustrial Accident Compensation Insurance (generally based on health insurance). As such, treatment
methods which are still in experimental or research stages are not included in these medical treatments.
(Note2) “No further medical effect can be expected "refers to a condition where no recovery or
improvement of injury or disease symptoms can be expected.

13

Claim Procedures●When claiming Medical Treatment Benefits
Submit a Medical Treatment Benefits Claims Form for Medical Compensation Benefits (Form No.
5) or a Medical Treatment Benefits Claims Form for Medical Treatment Benefits (Form No. 16-3)
to the chief of the relevant labour standards inspection office through the designated medical
facilities.
●When claiming treatment expenses
Submit a Treatment Expense Claims Form for Medical Compensation Benefits (Form No. 7) or a
Treatment Expense Claims Form for Medical Treatment Benefits (Form No. 16-5) to the chief ofthe relevant labour standards inspection office.
In addition, if receiving medication from a pharmacy, submit Form No. 7 (No. 16-5-2), receiving
treatment from a judo bonesetter, Form No. 7 (No. 16-5-3), from a acupuncturist, moxa specialist or
shiatsu massage therapist, Form No. 7 (No. 16-5-4) or when receiving home nursing from a homenursing company, Form No. 7 (16-5-5).
●Changing designated medical facilities, etc.
When a worker who is already receiving treatment at a designated medical facility, etc. changes
designated medical facilities due to returning to their home town or other reasons, a “Registration(of Change) of Designated Medical Facility, etc. where Medical Treatment Benefits for Medical
Compensation Benefits are Received” (Form 16) or “Registration (of Change) of DesignatedMedical Facility, etc. where Medical Treatment Benefits for Medical Treatment Benefits are
Received” (Form 16-4) to the chief of the relevant labour standards inspection office through thedesignated medical facilities,etc after changing.

Transportation Expenses
For hospital travel costs, the distance between worker’s residence or workplace and the medical facility mustin principle, be 2km or more. At least one of items following ①② ③ is required to be eligible for payment.
①Travel to an appropriate medical facility (*2) within the same village, city or town.
②Travel to an appropriate medical facility in a neighboring village, city or town because none is available
within the same village, city or town.(This includes situations where even if there is an appropriate medical
facility in the same village, city or town, travel to a facility in a neighboring village, city or town is easier)③Travel to the nearest possible appropriate medical facility in a village, city or town outside the same orneighboring village, city or town because no such facility exists there.
(*1) Travel costs may be paid in some circumstances even if the distance is less than 2km one-way.
(*2) Appropriate medical facility refers to a medical facility suitable for treatment of the relevant injury or
disease.

Statute of Limitations
Because Medical Treatment Benefits are benefits in kind, there are no issues with statute oflimitations on claim rights, however if claims are not made within 2 years of the day on whichcare expenses are paid, claim rights will lapse due to the statute of limitations.

14Temporary Absence from Work (Compensation)
療養（補償）給付について
Benefits
When a worker is injured or becomes ill as a result of work or commuting
and is unable to work in order to receive medical treatment, and thus
cannot earn wages, they can receive Temporary Absence from Work
Compensation Benefits (for employment injury) or Temporary Absencefrom Work Benefits (for commuting injury) beginning from the 4 the day of
the absence from work.

Benefits Details
When a worker fulfills the following 3 conditions, they can receive Temporary Absence from Work
(Compensation) Benefits and Temporary Absence from Work Special Allowances beginning fromthe 4th day of the absence from work.
① receiving medical treatment because of being injured or becoming ill as a result of work orcommuting,② being unable to work
③ being unable to earn wages
Temporary Absence from Work (Compensation) Benefits = (60% basic daily benefits payment
amount) ×No. of days of missed work
Temporary Absence from Work Special Allowances= (20% basic daily benefits payment amount)×No. of days of missed work
The first 3 days of missed work is called the waiting period and according to the Labour
Standards Law, for employment injury, during this time the employer shall provide Temporary
Absence from Work Compensation (60% of average wages per day).
In addition, for example, if the worker misses only a portion of their scheduled working hours for
hospital visits, they can receive 60% of the basic daily benefits payment amount for the wages ofthe missed time.

Claim Procedures
Submit a Temporary Absence from Work Compensation Benefits Claims Form (Form No.8) or a
Temporary Absence from Work Benefits Claims Form (Form No.16-6) to the chief of the relevantlabour standards inspection office.

Statute of Limitations
Claim rights for Temporary Absence from Work (Compensation) Benefits are earned for eachday on which a worker cannot work and earn wages because of medical treatment and if claims
are not made within 2 years of the following day, claim rights will lapse due to the statute oflimitations.

15

Injury and Disease(Compensation) Pension
療養（補償）給付について
When a worker was injured or became ill due to work-related causes and received
medical treatment for 1 year and 6 months, the worker is eligible to receive
Injury and Disease Compensation Pension (for employment injury) or Injury andDisease Pension (for commuting injury) from that day. The requirement are thefollowing conditions(1) The injuries or disease have not been cured.
(2) The severity of disabilities resulting from the injury or disease falls within the
Injury and Disease classifications of the Injury and Disease class table.

Benefit Details
Injury and Disease (Compensation) Pension, Injury and Disease Special Allowance and Injury andDisease Special Pension can be provided depending on the class of injury or disease
Injury and Disease(Compensation) Pension

Injury and Disease Special
Allowance (lump sum)

Class 1313 days of days of basic
daily
benefit payment amount

1,140,000 yen

313 days of days of basic daily
calculation amountClass 2277 days of days of basic
daily
benefit payment amount

1,070,000 yen

277 days of days of basic daily
calculation amountClass 3245 days of days of basic
daily
benefit payment amount

1,000,000 yen

245 days of days of basic daily
calculation amount

Injury/diseas
e class

Injury and Disease Special
Pension

給され、毎年２月、４月、６月、８月、
Pension Payment Months
ます。
Injury and Disease (Compensation) Pension is paid for amount of the previous 2 months 6 times
every year in February, April, June, August, October and December. The payment starts thefollowing month when the above conditions (1) and (2) are met.
※ Workers who have suffered a class 1 or 2 injury or disease and have a thoracoabdominal organ, nervous systemor mental disability and who are already receiving nursing care can receive Nursing Care (Compensation)
Benefits. ( → P32)

Procedures
Determination of whether Injury and Disease (Compensation) Pension will be provided or not ismade under the authority of the chief of the relevant labour standards inspection office, so
no claims procedures are required, however if injuries or diseases are not cured within 1 year and 6
months from beginning the care, within 1 month thereafter a “Notification of Injury and Disease
Conditions (Form No. 16-2)must be submitted to the chief of the Labour standards inspection office.
16

Disability(Compensation) Benefits
療養（補償）給付について
When a worker is injured or becomes ill as a result of work or commuting,once the injury or disease is cured (stabilized symptoms), if any disabilities
remain, the worker can receive Disability Compensation Benefits (foremployment injury) or Disability Benefits (for commuting injury)

Benefit Details
If remaining disabilities fall within the disability classifications listed in the disability classification table, thefollowing benefits can be provided depending on the severity of the disability.
●For class 1 through class 7 disabilities Disability (Compensation) Pension, Disability Special Allowance,
Disability Special Pension●For class 8 through class 14 disabilities Disability (Compensation) Lump Sum, Disability Special Allowance,
Disability Special Lump Sum
Disability class

Disability (Compensation) B enef its
313 days of days of basic daily benefit
payment amount

Disability Special

Disability Special Pension

Allowance(※ )Disability Special Lump Sum

313 day s of day s of basicdaily
calculation am ount

Class 1

PensionClass 2

〃

277

〃

〃

3,200,000 yen

〃

277

〃

Class 3

〃

245

〃

〃

3,000,000 yen

〃

245

〃

Class 4

〃

213

〃

〃

2,640,000 yen

〃

213

〃

Class 5

〃

184

〃

〃

2,250,000 yen

〃

184

〃

Class 6

〃

156

〃

〃

1,920,000 yen

〃

156

〃

Class 7

〃

131

〃

〃

1,590,000 yen

〃

131

〃

Class 8Lum p Sum

503

〃

〃

650,000 yen

Lum p Sum

Lump Sum 3,420,000 yen Pension

Disability Special Lump Sum

503 day s of day s of base daily
calculation am ount

Class 9

〃

391

〃

〃

500,000 yen

〃

391

〃

Class 10

〃

302

〃

〃

390,000 yen

〃

302

〃

Class 11

〃

223

〃

〃

290,000 yen

〃

223

〃

Class 12

〃

156

〃

〃

200,000 yen

〃

156

〃

Class 13

〃

101

〃

〃

140,000 yen

〃

101

〃

Class 14

〃

56

〃

〃

80,000 yen

〃

56

〃

*If the worker has already received an Injury and Disease Special Allowance for the same accident, it will be
subtracted from the amount paid.
* Workers who have suffered a class 1 or 2 injury or disease and have a thoracoabdominal organ, nervous systemor mental disability and who are already receiving nursing care can receive Nursing Care (Compensation)
Benefits. ( → P32)

Claim Procedures
Submit “Disability Compensation benefits Claims Form” (Form 10) or “Disability benefits
Claims Form” (Form 16-7) to the chief of the relevant labour standards inspection office
Statute of Limitations on Claims
If claims for Disability (Compensation) Benefits are not made within 5 years of the following day
injuries or diseases are cured(stabilized symptoms), claim rights will lapse due to the statute oflimitations.
17Disability Class Table
Industrial Accident Compensation Insurance Act Enforcement OrdinanceAppendix Table 1 Disability Class Table
Disability
class
障害等級

給付の内容
Benefit Details

身体障害Physical
Disability

Disability classBenefit
Details
給付の内容

１1 両眼が失明したもの
Has lost vision in both

２eyes
そしゃく及び言語の機
能を
2 Has廃したもの
lost digestive and３speech
神経系統の機能又はfunctionsClass 1

第１級

313 days ofthe basic daily
当該障害のbenefits
存する期間
payment
１年につきamount for 1
給付基礎日year while the
額のdisability is
313日分
present

3 Has significant
精神に著しい障害を残disabilities with 要する もし、常に介護を
nervous system or mentalのdisability and requires

５ 削除
constant nursing care
６ 両上肢を ひじ関節以上

第４級
Class
4

5. Deletedで失ったもの6 Has lost both arms
７above両上肢の用を
the elbow 全廃したもの
7 Has lost use of both arms
Has lost bothlegs関節以上
above
８8 両上肢をひざ
the knee
で失ったものHas lost the use of
both
９9 両上肢の用を
全廃した
legs

213
同Same
213日分
days

もの

and vision in other eye is
視力が0.02以下になっ0.02 or less
たもの

Same 277

同 days277日分

視力が0.06以下になっand vision in other eye is

１の２
less 神経系統の機能又は精1-2 Has significant disabilities
神に著しい障害を残し、特に軽with nervous system or
易な労務以外の労務に服する
mental disability, and cannot
ことができないもの
perform any but the simplestof work
１の３
胸腹部臓器の機能に著
1-3
Has
significant
disabilities
しい障害を残し、特に軽易なwith thoracoabdominal organ
労務以外の労務に服する こと
function, and cannot performができないものany but the simplest of work
Has lost 1手関節以上で失っ
arm above the２ 2１上肢をhand
たもの
3 Has lost 1 leg above the
３ foot１下肢を 足関節以上で失ったもの
4 Has lost use of 1 arm
Has lost use of全廃したもの
1 leg
４ 5１上肢の用を6 Has lost all the toes on both
５ １下肢の用を 全廃したもの
feet
６ 両足の足指の全部を 失った

Has lost digestive or
２2 そしゃく又は言語の機
speechfunctions
能を 廃したもの

もの
１ 1両眼の視力が0.1以下になっ
Vision in both eyes is under 0.1

2 Vision in both eyes is
２ 両眼の視力が0.02以
0.02 or less下になったもの
2-2 Has significant
２の２
神経系統の機能disabilities
with nervous
又は精神に著しい障害
system or mental
disability
and requires on
を残し、随時介護を要す
callものnursing careる
2-3 Hassignificant
２の３
胸腹部臓器の機
disability with
能に著しい障害を 残し、
thoracoabdominal organ
随時介護を 要する もの
function and requires on
３call
両上肢を
手関節以上
nursing care
で失ったもの3 Has lost both arms
４above
両上肢を足関節以上
the hands
で失ったもの4 Has lost both legs above
feet
１the
1 １眼が失明し、他眼のHas
lost vision in 1 eye

Class
5
第５級

Same 184

同days
184日分

たもの
0.06 or lessHas significant disabilities
３3 神経系統の機能又は
Class
3
第３級

Same 245

同 days245日分

１1 両眼の視力が0.06以下になっ
Vision in both eyes is under
たもの
0.06
Has significant disability
２2 そしゃく及び言語の機能に著
with speech or digestive
しい障害を 残すもの
functions３3 両耳の聴力を全く失ったもの
Is completely deaf
in both４ears
１上肢を ひじ関節以上で失っ4たもの
Has lost 1 arm above theelbow
５ １下肢を ひざ 関節以上で失っ
5 Has lost 1 leg above the knee
6たもの
Has lost the use of all fingers
both hands
６on 両手の手指の全部の用を廃7したもの
Has lost both feet above theLisfranc joint
７ 両足を リスフラ ン 関節以上で失ったもの
１ １眼が失明し、他眼の視力が
1 Has lost vision in 1 eye, and
0.1以下になったもの
vision in other eye is 0.1 or

Has lost vision in 1 eye
１1 １眼が失明し、他眼の

Class
2
第２級

身体障害
Physical
Disability

2 Has significant disability withたもの
speech or digestive functions
２ 3そしゃく又は言語の機能に著
Hearing in both ears is suchwith nervous system or
精神に著しい障害を 残
mental disability and cannot
し、終身労務に服する
work a lifetime job
ことができないもの
4 Has significant disability
４with
胸腹部臓器の機能に
thoracoabdominal
著しい障害を残し、終身organ function andcannotwork a lifetime job
労務に服する
ことができ
5 Has lost all fingers on bothないもの
５hands
両手の手指の全部を

Class
6
第６級

Same 156
同days
156日分

that even loudspeaking cannot
しい障害を
残すもの
be heard unless directly near the
３ 両耳の聴力が耳に接しなけ
ear

れば大声を
解する
ことができ
3-2 Has lost hearing
completelyin
1 ear and hearing in remaining
ない程度になったもの
ear is of a level that it is difficult

３の２
１耳の聴力を全く失い、
to hearnormal conversation
further than 40 centimeters
他耳の聴力が40セン
チメート
ル以上の距離では普通の話

失ったもの

18

Disability

Disability
障害等級
Class

Benefit
給付の内容
Details

障害等級
Class

Physical
Disability
身体障害

1 Has lost vision in 1 eye or

力が0.02以下になったもの
vision in 1 eye is 0.02 or less

2 Has mobility impairmentin
２ せき柱に運動障害を
残すもの
spine

３ １手の母指を含み２の手指又3 Has lost 2 fingers
includingthe thumb or 3 fingers
は母指以外の３の手指を失っ
excluding the thumb on 1 handたもの
4 Has lost use of 3 fingers

including the thumbor 4 fingers
４ １手の母指を含み３の手指又excluding the503 days

Class 8を 含み４の手指を 失ったもの

第８級

１ １眼が失明し、他眼の視Same 131

同days
131日分

Physical Disability
身体障害

１ １眼が失明し、又は１眼の視声をことができな4 Has解する
significant
い程度になったっもの
deformation or mobilityin spine
４ impairment
せき柱に著しい変形又は5 Has lost use残すもの
of 2 of the 3
運動障害をmajor joints in 1 arm
５ １上肢の３大関節中の２6 Has lost use of 2 of the 3
関節の用を
廃したもの
major joints in
1 leg
６ 7１下肢の３大関節中の２Has lost all 5 fingers or 4
fingers including
the
関節の用を
廃したもの
thumb
on
1
hand
７ １手の５の手指又は母指

Class
7
第７級

Benefit

給付の内容
Details

1 Has lost vision in 1 eye and
力が0.6以下になったもの
vision in other eye is 0.6 or
２ less
両耳の聴力が40セン チ
2 Hearing in both ears is of a
メートル以上の距離ではlevel that it is difficult to
普通の話声を解する ことhear normal conversation
furtherthan40ができない程度になった
centimeters
もの
2-2 Has lost hearing
completelyin 1 ear and全く失２の２
１耳の聴力を
hearing in remaining
い、他耳の聴力が１メート
ear is of a level that it is
ル以上の距離では普通のdifficult to hear normal
conversation
furtherthan 1
話声を解することができな
meter
い程度になったもの
3 Has significant disabilities
３ with
神経系統の機能又は精nervous system or
mental disability,
and
神に障害を
残し、軽易な労
cannot perform any
務以外の労務に服するこ
but the simplest of work
4 DeletedとができないものHas significant disabilities
４ 5削除
with thoracoabdominal
５ organ
胸腹部臓器の機能に障function, and cannot
performany but the
害を 残し、軽易な労務以
simplest of work
外の労務に服する
ことが6 Has lost 3 fingers including
できないものthe thumb or 4 fingers
the thumbon 1
６ excluding
１手の母指を含み３の手
hand
指又は母指以外の４の手
7 Has lost use of all 5 fingers
or 4 fingers
including the
指を失ったもの
on 1 hand
７ thumb
１手の５の手指又は母
8 Has lost 1 foot above the
指を含み４の手指の用を
Lisfranc
joint
9 Has pseudoarthrosis and
廃したもの
significant mobility
８ impairment
１足を リスフラン 関節以上in 1 arm
で失ったもの10 Has pseudoarthrosis andmobility
９ significant
１上肢に偽関節を残し、impairment in 1 leg
著しい運動障害を残すもの
11 Has lost the use of all
on both feet
10toes１下肢に偽関節を残し、12 Has significant external
著しい運動障害を 残すもの
appearance issues
1113両足の足指の全部の用
Has lost both testis

給付基礎日額of days ofの basic daily

benefits
503日分
payment
amountは母指以外の４の手指の用を
thumb on 1 hand
5 1 leg has been shortened by 5
廃したもの
centimeters or more

５ １下肢を
6 Has lost５セン
use of チメートル以上
1 of the 3
major joints in 1 arm
短縮したもの7 Has lost use of 1 of the 3６ １上肢の３大関節中の１関節
major joints in 1 leg
8 Has pseudoarthrosisの用を廃したもの and in 1
arm

７ １下肢の３大関節中の１関節
9 Has pseudoarthrosis and in 1
leg 廃したものの用を10 Has lost all toes on 1 foot

８ １上肢に偽関節を 残すもの
９ １下肢に偽関節を 残すもの
10 １足の足指の全部を 失ったもの１ 両眼の視力が0.6以下になったもの
1 Vision in both eyes is 0.6 orless
２ １眼の視力が0.06以下になっ
2 Vision in 1 eye is 0.06 or lessたもの
3 Has hemiamaurosis, tunnel

visions or deformed vision in
３ 両眼に半盲症、視野狭さく又both eyes
4 Has significant
impairment inは視野変状を残すもの
the eyelids of both eyes

４ 両眼のまぶたに著しい欠損を
5 Has lost the nose or has
significant impairment in the
残すもの
function of the nose

５ 鼻を
6 Has欠損し、その機能に著し
disability with digestiveand speech
function
い障害を残すもの

6-2 Hearing in both ears is of a

６ そしゃく及び言語の機能に障level that it is difficult to hearnormalconversation further
害を
残すもの
Class
9
第９級

391
同Same
391日分
days

than 1 meter６の２
両耳の聴力が１メートル
6-3 Hearing
in 1 ear is so poorthat loud voices cannot be
以上の距離では普通の話声をheard even close by and

解することができない程度に
hearingin the remaining
ear is of a level that it is difficult
なったもの
to hear normal conversation

６の３
１耳の聴力が耳に接しな
furtherthan 1 meter7 Has completely
lost hearingin
ければ大声を
解する
ことができ
1 ear

ない程度になり、他耳の聴力が7-2 Has disabilities with
nervous system or mental
１メートル以上の距離では普通
disability which limitsの話声をことが困難でthe level 解するof work thatcan beperformed
ある程度になったものを 廃したものすもの

７ １耳の聴力を 全く失ったもの
７の２ 神経系統の機能又は精13 両側のこう丸を 失ったも神に障害を 残し、服する こと

12 外ぼうに著しい醜状を 残の19

Disability
障害等級
Class

Class 10
第10級

Benefit
給付の内容
Details

Same 302
同days
302日分

Disability

Physical
Disability
身体障害

障害等級
Class

ができる 労務が相当な程度
7-3 Has disability withに制限される もの
thoracoabdominal organ
７の３
胸腹部臓器の機能にfunction
which limits the
障害を
level of残し、服する
work that can be
performed 労務が相当なことができる
8 Has lost thumb orもの
2程度に制限される
fingers excluding thumb on
８ １手の母指又は母指以外
1 handの２の手指を
9 Has lost use 失ったもの
of 2 fingers
９ including
１手の母指を含み２の手指thumb,
or 3
fingers excluding thumb on
又は母指以外の３の手指の1 hand用を 廃したもの
10 Has lost 2 or more toes,
10 including
１足の第１の足指を含み
big toe on 1 foot２以上の足指を11 Has lost use of失ったもの
all toes on
foot
11 1 １足の足指の全部の用を
11-2 Has considerable
廃したもの
external appearance issues
11の2 外ぼうに相当程度の12 Has significant disability
醜状を残すものwith genitals
12 生殖器に著しい障害を 残すもの
１ 1１眼の視力が0.1以下にVision in 1 eye is 0.1 or
less
なったもの
1-2 Hasdiplopia in visionas
１の２
正面視で複視を残す
frontal vision
もの
2 Has disability with
２ digestive
そしゃく又は言語の機能
or speechに障害をfunctions 残すもの
Has dental prosthetics in
３ 314歯以上に対し歯科補
14 or more teeth
てつを 加えたもの
3-2 hearing in both ears is of
３の２
両耳の聴力が１メー
a levelthat it is difficult to
トル以上の距離では普通
hear normal conversation
further than
1 meterの話声を解する
こ
4 Hearing in 1 ear程度になっ
is suchとが困難であるthat even loud speaking
たもの
cannot be heard unless
４ directly
１耳の聴力が耳に接しな
near the ear
ければ大声を解する ことが5 Deleted
6 Has lost use of thumb or 2
できない程度になったもの
fingers excluding thumb on
５ 削除
1 hand
６ 7１手の母指又は母指以外
1 leg has been shortenedの２の手指の用をby 3 centimeters or廃したもmore
8 Has lost big toe or other 4のon 1 foot７ toes
１下肢を３セン チメートル
9 Has significant disability in
以上短縮したもの
function of 1 of the 3 major
８ joints
１足の第１の足指又は他
in 1 armの４の足指を失ったもの
10 Has significant
disability
function of 1 of the 3
９ in
１上肢の３大関節中の１major joints in 1 leg
関節の機能に著しい障害を 残すもの
10 １下肢の３大関節中の１関節の機能に著しい障害を
残すもの

20

Benefit

給付の内容
Details

Physical
Disability
身体障害

１ 1両眼の眼球に著しい調節機能
Has significant disability
障害又は運動障害を残すもの
with modulation functionormobility
impairment
inboth
２ 両眼のまぶたに著しい運動障
eyes
害を
残すもの
2 Has significant mobility
３ impairment
１眼のまぶたに著しい欠損をin the eyelids of
both
eyes
残すもの
3 Has significant loss of the３の２
10歯以上に対し歯科補て
eyelid of 1 eye

つを
3-2 加えたもの
Has dental prosthetics in
10ormore teeth
３の３ 両耳の聴力が１メートル以3-3 Hearing in both ears is
上の距離では小声を解する ことof a level that it is difficult
Class
11
第11級

233
同Same
223日分
Days

ができない程度になったもの
to hear quiet conversation
than 1meter チメート
４ further
１耳の聴力が40セン
4 Hearing in 1 ear is of a
ル以上の距離では普通の話声
level that it is difficult to
をhear
解する
ことができな程度にな
normalconversation
further than 40 centimetersったもの
5 Has deformation of spine
５ 6せき柱に変形を残すもの
Has lost index finger,
６ middle
１手の示指、中指又は環指を
finger or ring finger
on 1 hand
失ったもの
7 deleted
７ 8削除
Has lost use of 2 toes
８ including
１足の第１の足指を
big toe on 1含み２以
foot

9 Has disability with
上の足指の用を廃したもの
thoracoabdominal organ
９ function
胸腹部臓器の機能に障害をwhich presents
残し、労務の遂行に相当な程度
significant impairment toexecution of workの支障があるもの１ 1１眼の眼球に著しい調節機能
Has significant disability withmodulation function or 残すもの
mobility
障害又は運動障害をimpairment in 1 eye
２ 2１眼のまぶたに著しい運動障
Has significant mobility
impairment
in the eyelid of 1 eye
害を残すもの
3 Has dental prosthetics in 7 or
３ more７歯以上に対し歯科補てつを
teeth
4 Has lost majority of the auricle
加えたもの
the pinna of 1 ear

４ 5１耳の耳かくの大部分を
Has significant deformation欠損し
ofcollarbone,sternum, ribs, shoulder
たもの
blade or pelvic bone
５ 6鎖骨、胸骨、ろく骨、肩こう骨又Has significant disability of
第12級
Class
12

同Same
156日分
156
days

function in 1 of 3 major joints残すもin
は骨盤骨に著しい変形を
armの7 Has significant disability ofin 1 of 3 major joints in leg
６ function
１上肢の３大関節中の１関節
8 Has deformation of long bonesの機能に障害を残すもの
8-2 Has lost pinky finger
on 1 hand
Has lost use of index finger,
７ 9１下肢の３大関節中の１関節
middle finger or ring finger on oneの機能に障害を残すもの
hand
Has lost 2nd toe, 残すもの
has lost 2 toes
８ 10
長管骨に変形をincluding 2nd toe or has lost 3 toes

８の２
１手の小指を
excluding
2nd toe on失ったもの
1 foot９ １手の示指、中指又は環指の用を 廃したもの
10 １足の第２の足指を 失ったもの、第２の足指を 含み２のDisability
障害等級
Class

Benefit

給付の内容
Details

Disability

Physical身体障害
Disability

障害等級
Class

Benefit

給付の内容
Details

足指を 失ったもの又は第３の足指以外の３の足11 Has lost use of big toe
or 4失ったもの
other toes on 1 foot
指を
12
Has
obstinate
11 1足の第１の足指又はlocalized nervous
他の４の足指の用を 廃
symptoms
したもの
14 Has external
12 appearance
局部にがん固な神経
issues症状を 残すものHas lost the use of the 廃し
10 10
１足の第２の足指の用を
second toe of 1 foot, use of
たもの、第２の足指を含み２の2 toes including the second

第13級
Class
13

同Same
101日分
101
Days

2 Has dental prosthetics in 3 orの

２ more３歯以上に対し歯科補てつを
teeth
2-2
Hearing加えたもの in one ear is of alevel that it is difficult to hear
２の２
quiet１耳の聴力が１メートル以conversation further than

１ １１眼の視力が0.6以下
Vision in 1 eye is 0.6 orClass 13

第13級

Same 101

同Days
101日分

toe, or those
who have lost
足指の用を廃したもの又は第３the use of the three toesの足指以下の３の足指の用を
other than the big
and second toes
廃したもの

1 1１眼のまぶたの一部に欠損を
Has partially lost eyelid but
still
has eyelashes in 残すもの
1 eye
残し、又はまつげを14 外ぼうに醜状を 残すもになったものless
Has hemiamaurosis,
２ 2 １眼に半盲症、視野狭tunnelvisions or
さく又は視野変状を残す
deformed
ものvision in 1 eye
２の２
正面視以外で複視2-2 Hasdiplopia in vision
を
残すもの
other
than frontal vision
Has partial loss of
３ 3 両眼のまぶたの一部
eyelids or loss
ofに欠損を残し又はまつeyelashes in 1 eye
げはげを 残すもの
3-2 Has dental
３の２５歯以上に対し歯prosthetics
in 5 or more
科補てつを
加えたもの
teeth
3-3 Hasdisability with
３の３
胸腹部臓器の機
thoracoabdominal
organ
能に障害を
残すもの
function
４ １手の小指の用を 廃し4 Has lost use of pinky
たもの
finger in 1 hand
５ 5 １手の母指の指骨のHas lost part of thumbbones in失ったもの
1 hand
一部を
6
Deleted
６ 削除
7 Deleted
７ 削除
8 1 leg has been
８ shortened
１下肢をby１セン
チ メート
1 centimeter
ル以上短縮したもの
or moreHas lost either or both
９ 9 １足の第３の足指以下
4thand 5th toes on 1 footの１又は２の足指を失っ

Physical
Disability
身体障害

1 meter上の距離では小声を解する こ
3 Has appearance deformityとが出来ない程度になったもの
the size of the palm on thesurfaces of arms
３ exposed
上肢の露出面にてのひらの大4 Has appearance deformity

Class
第14級
14

Same 56
同 Days56日分

きさの醜いあとを残すもの
the size of the palmon theexposedsurfacesoflegs
４ 下肢の露出面にてのひらの大5 Deleted
きさの醜いあとを
6 Has lost portion 残すものof the bones
1 finger other than the
５ of削除thumb on 1 hand
６ 7１手の母指以外の手指の指骨
Has become unable to extend
and
contract
the last joint of
の一部を
失ったもの
any finger, except the thumb,７ on
１手の母指以外の手指の遠位
1 hand8Haslost use ofeither orことがboth
指節間関節を屈伸する
4th and 5th toes on 1 footで9 Has localized nervous
symptoms
きなくなったもの
８ １足の第３の足指以下の１又は２の足指の用を 廃したもの
９ 局部に神経症状を 残すもの

たもの

Notes
1 Vision shall be measured in accordance with international visual acuity measurement standards.
The vision of those with some abnormality in refraction shall be measured in relation to correctedvision.
2 “Has lost fingers" means “has lost, for the thumb, the part upward of the thumb joint, and for theother fingers, the parts upward of the first joint".
3 “Has lost the use of fingers" means “has lost half or more of the finger tip" or “has serious
mobility impairment to the middle finger joints or the first finger joints (for the thumb, the thumbjoint)"
4 “Has lost toes” means having lost all the specified toes.
5 “Has lost the use of the toes" means “has lost, for the big toe, half or more of the tip of the toe, andfor the other toes, the part above the toe tip joint", or “has serious mobility impairment in the middle
toe joints or the first toe joints (for the big toe, the toe joint)"

21

Disability (Compensation) Pension
Prepaid Lump Sum
Claimant’s eligible to receive disability (compensation) pension can opt to receive a 1 time lumpsum prepayment instead.

Benefit Details
The amount of the prepaid lump sum can be selected from the fixed amounts below which areestablished based on the class of the relevant disability (refer to the table below).
If a prepaid lump sum is paid, the monthly disability (compensation) pension payments will cease
until such time as they have reached the amount of the prepaid lump sum (lump sums which exceed asingle year’s portion will be reduced by the amount of 5 % simple interest a year).
Disability
Class

Prepaid Lump Sum AmountClass 1 basic daily
Class 2
Class 3
Class 4
Class 5Class 6Class 7200 days, 400 days, 600 days, 800 days, 1000 days, 1200 days or 1340 days
Calculation amount
200 days, 400 days, 600 days, 800 days, 1000 days or 1190 days〃
200 days, 400 days, 600 days, 800 days, 1000 days or 1050 days〃
200 days, 400 days, 600 days, 800 days or 920 days〃
200 days, 400 days, 600 days, or 790 days〃
200 days, 400 days, 600 days, or 670 days〃
200 days, 400 days or 560 days〃

Claim Procedures
When making a claim for a disability (compensation) pension prepaid lump sum, in principle a“Disability Compensation Pension/Disability Pension Prepaid Lump Sum Claims Form” (Pension
Application Form No. 10) should be submitted together with the claim for disability (compensation)pension to the chief of the relevant labour standards inspection office. However, a claim can bemade even after receiving disability (compensation) pension payments if the claim is made within
one year of the day following receipt of the pension payment determination notice. In this situation,
the claim should be for an amount within the scope of an amount where the already paid amount of
the pension is subtracted from the maximum possible amount for the relevant disability class.

Statute of Limitations
Note that the statute of limitation of claim right for disability (compensation) pension prepaid
lump sum is 2 years after the next day when disease or injury is cured(stabilized symptoms)

22

Disability (Compensation) Pension Balance Lump Sum
In the event a person eligible for Disability (Compensation) Pension dies, if the already paid total
amount of Disability (Compensation) Pension and Disability (Compensation) Pension Prepaid Lump
Sum is lower than the fixed amount set for the relevant disability class, a Disability (Compensation)
Pension Balance Lump Sum can be provided to surviving family.

Benefit Details
The amount of the Disability (Compensation) Pension Balance Lump Sum will be an amount fromthe following table based on the class of disability minus the total amount of Disability(Compensation) Pension Prepaid Lump Sum In addition, there is a balance lump sum payment
system for Disability Special Pension as with the Disability (Compensation) Pension.

Disability

障害等級
Class
第１級

Class 1
第２級
Class
2
第３級
Class
3
Class
4
第４級
Class
5
第５級
Class 6
第６級Class 7

第７級

Disability (Compensation)

障害（補償）年金差額一時金
Pension Balance Lump Sum
給付基礎日額のDisability Special Pension

障害特別年金差額一時金
Balance Lump Sum

１，３４０日分 算定基礎日額の１，３４０日分

basic daily calculation amount
1,340
basic daily benefits amount × 1,340〃
１，１９０日分〃
１，１９０日分
days
days
〃〃
1,190 days
１，０５０日分
１，０５０日分〃〃
1,190 days〃
1,050 days
〃〃
1,050
days
９２０日分
〃
９２０日分
〃
920 days〃
920 days
〃
７９０日分
〃
７９０日分
〃
790 days〃
790 days〃
670 days
６７０日分
〃
６７０日分
〃〃
670 days〃
560 days〃〃
560 days
５６０日分
〃
５６０日分

●Surviving family which can receive Disability (Compensation) Pension Balance Lump Sum
The surviving family which can receive Disability (Compensation) Pension Balance Lump Sum
must meet the conditions provided in (1) or (2) below, with the priority for reception being thefor those listed in (1) and (2)(1) Spouse (including those who have not submitted a marriage registration but were
engaged in a common law marriage with the worker, this applies for category (2) as well), child,parent, grandchild, grandparent and sibling who depended on the worker’s income for theirlivelihood at the time of the worker’s death.
(2) Spouse, child, parent, grandchild, grandparent and sibling other than those listed
above in (1).

23

Claim Procedures
When making a claim for a disability (compensation) pension balance lump sum, submit aDisability Compensation Pension Balance Lump Sum/Disability Pension Balance Lump Sum
Payment
Claims Form (Form No. 37-2) to the chief of the relevant labour standards inspection office.
● Attachments required when submitting a claim
こういうときは
Station

添付書類
Attachment

Must be attached in all cases
必ず添付するもの

Family register certified copy or extract or other
戸籍の謄本又は抄本等の請求人と死亡した労働
materials
which certify a relationship with the者との身分関係を証明することができる書類
deceased
worker

If living in a marriage relationship with the
死亡労働者と婚姻の届出をしていないが事実
deceased worker but have not filed a marriage
上婚姻関係と同様の事情にあった場合
registration

Materials
proving the relationship and circumstances
その事実を証明する書類

If your livelihood was dependent upon the
死亡労働者の収入によって生計を維持していincome of the deceased worker
た場合

Materials
proving the relationship and circumstances
その事実を証明する書類*Submission of materials other than those listed may be required.

Statute of Limitations
If claims for Disability (Compensation) Pension Balance Lump Sum are not made within 5
years of the day following the day the recipient died, claim rights will lapse due to the statute oflimitations .

24

Surviving Family (Compensation) Benefits
療養（補償）給付について
Funeral Expenses (Funeral Rites Benefits)
When a worker dies as a result of work or commuting, the survivingfamily can receive Surviving Family (Compensation) Benefits. In
addition, Funeral Expenses (Funeral Rites Benefits) can be provided tothose holding a funeral for the deceased.
Surviving Family (Compensation) Benefits consist of 2 types, “Surviving Family(Compensation) Pension” and “Surviving Family (Compensation) Lump Sum”.

Surviving Family (Compensation) Pension
Surviving Family (Compensation) Pension is paid to the highest priority member(called the “eligible recipient”) among the “qualified recipients”

Qualified Recipients
Qualified recipients for Surviving Family (Compensation) Pension are spouse, child, parent,
grandchild, grandparent and sibling of the worker who depended on the worker’s income for their livelihood
at the time of death, however for surviving family other than the wife the individuals must be above or below
set ages or suffering from certain disabilities at the time of the worker’s death to be eligible.
In addition, “depended on the worker’s income for their livelihood at the time of death” does not mean
only those who were mainly or chiefly supported by the worker’s income, but rather simply having been
dependent on the worker’s income for a portion of the livelihood is sufficient, including 2 income families.
The order of priority of eligible recipients is as follows.
①Wife or a husband who is 60 years or older or suffers from certain disability②Child who has not yet reached the first March 31st after their 18th birthday or who suffers from certain
disability③Parent who is 60 years or older or suffers from certain disability④Grandchild who has not yet reached the first March 31st after their 18th birthday or who suffers from certain
disability⑤Grandparent who is 60 years or older or suffers from certain disability⑥Sibling who has not yet reached the first March 31st after their 18th birthday, is 60 years or older, or who
suffers from certain disability⑦Husband who is between 55 and 60 years old⑧Parent who is between 55 and 60 years old⑨Grandparent who is between 55 and 60 years old⑩Sibling who is between 55 and 60 years old* Certain disability refers to a physical disability of disability class 5 or higher.
* For spouse this includes those who have not submitted a marriage registration but lived in a marriage relationshipwith the deceased. In addition, any unborn children at the time of the worker’s death become qualified recipientsat birth.
* If the priority recipient dies or remarries, or otherwise loses their right to receive the benefits, the person with thenext highest priority becomes the eligible recipient.
* Even if the husband, parent, grandparent or sibling between 55 and 60 years old in items⑦-⑩are the eligible
recipients, pension will not be supplied until they reach 60 years old.

25

Benefit Details
Surviving Family (compensation) pension, surviving Family special allowance and surviving
Family special pension can be provided depending on the number of surviving family.
If there are 2 or more eligible recipients, the amount received by each recipient will be devided of the total.
No. ofsurviving

Surviving family (compensation)

Special survivor

pensionpayment (lump sum)

familySpecial survivor pension

1 persona

153 day s of basic daily benefits pay ment amount (175 day sof day s of basic daily benefits pay ment amount for surviving
spouse of over 55 y ears old, or with a designated disability

153 day s of basic daily calculation amount (175 day s ofday s of basic daily calculation pay ment amount for surviving
spouse of over 55 y ears old, or with a designated disability ).

2 personas

201 day s of day s of basic daily benefits pay ment amount

3 personas

223 day s of day s of basic daily benefits pay ment amount

223 day s of day s of basic daily calculation amountMas de 4 personas

245 day s of day s of basic daily benefits pay ment amount

245 day s of day s of basic daily calculation amount

3,000,000 yen

201 day s of day s of basic daily calculation amount

Claim Procedures
Submit a Surviving Family Compensation Pension Payment Claims Form (Form No. 12) or a Surviving Family
Pension Payment Claims Form
(Form No. 16-8) to the chief of the relevant labour standards inspection office.
Application for provision of special allowances should, in principle, be made at the same time as claims for surviving
Family (compensation) benefits and use the same form as surviving Family (compensation) benefits.

●Materials required when submitting*Submission of materials other than those listed may be required.
Situation

Attachments
Death certificate, postmortem certificate, autopsy report, or certificate of details of
such, or other materials which certify the circumstances and date of the worker's
death
Family register certified copy or extract or other materials which certify the
relationship between the claimant and other qualified recipients with the deceased
workerMaterials certify ing that the claimant or other qualified recipients were dependent
upon the income of the deceased worker

Must be attached in all cases

If the claimant or another qualified recipient was living in a marriage relationship withthe deceased worker but had not filed a marriage registration

Materials proving the relationship and circumstances

If there the claimant or another qualified recipient is a qualified recipient because ofcertain disabilities

Medical certificate or other materials which certify the relevant person still suffersfrom the disability after the worker's deathIf any of the qualified recipients' livelihoods was tied to that of the deceased worker‘s

Materials proving the relationship and circumstances

If the worker's wife is disabled

Medical certificate or other materials which certify the wife still suffers from thedisability after the worker's death, that the disability began after the worker's deathor that the disability is no longer an issue

If receiving surviving Family pension, basic surviving Family pension, widow's pension,etc. for the same reasons

Materials showing the amount of benefits received

Statute of Limitations
If claims for surviving family (compensation) pension are not made within 5 years of the day
following the day the recipient died, claim rights will lapse due to the statute of limitations.

26

Surviving Family (Compensation) Lump Sum（１）Surviving Family (Compensation) Lump Sum
It will be provided ｉｎ ａｎｙ of the following circumstances① If no surviving family eligible to receive Surviving Family (Compensation) Pension exists at thetime of the worker’s death② If all eligible Surviving Family (Compensation) Pension recipients down to those with thelowest priority should lose their claim rights, or if the total amount of pension and surviving
Family (compensation) pension prepaid lump sum paid (P29) to eligible surviving family
totals less than 1000 days worth of the basic daily benefits amount（２）Eligible recipient
Eligible recipients for surviving family (compensation) lump sums are those from the following
list in order of priority (for ②and ③the order of priority is child, father, mother, grandchild,grandparent) and if there are 2 or more eligible recipients at the same priority, each will betreated as eligible recipients.
①Spouse②Child, parent, grandchild or grandparent who depended on the worker’s income for
their livelihood at the time of death.
③Other child, parent, grandchild or grandparent④Sibling

Benefit Details
For situation (1) ① above

1,000 days of the basic daily benefits payment amount will be provided. In addition
to 3,000,000 yen being provided as surviving family special allowance, 1,000 daysof the basic daily calculation amount will be provided as surviving family special
lump sum.
For situation (1) ② above
1,000 days of the basic daily benefits payment minus total amount of Surviving
Family Special Pension already paid is provided.
If the total amount of Surviving Family Special Pension paid to all eligible
recipients is less than 1000 days worth of the basic daily calculation amount, aSurviving Family Special Lump Sum consisting of an amount equal to 1000 days
worth of the basic daily calculation minus the already paid total shall be provided.
(Surviving family Special Allowances is not provided in these circumstances.)27

Claim Procedures
Submit a Surviving family Compensation Lump Sum Claims Form (Form 15) or Surviving family
Lump Sum benefits Claims Form (Form 16-9) to the chief of the relevant labour standards
inspection office.
Application for provision of surviving family special pension should, in principle, be made at thesame time using the same form as Surviving Family (Compensation) Lump Sum Money.
●Materials required when submitting

Situation

Materials

If living in a marriage relationship with the deceased worker but have not
filed a marriage registration

Materials proving the relationship and circumstances

If your livelihood was dependent upon the income of the deceased worker

Materials proving the relationship and circumstances

If there is no surviving family who is qualified to receive Surviving Family
Compensation benefits when the worker diesa. Death certificate, postmortem certificate, autopsy report, or
certificate of details of such, or other materials which certify
the circumstances and date of the worker's deathb. Family register certified copy or extract or other materials
which certify the relationship between the claimant and otherqualified recipients with the deceased worker※この他にも書類を提出していただく場合があります。
If all eligible surviving family compensation pension recipients down tothose with the lowest priority should lose their claim rights, and the total
Materials from “b” above
amount of pension and surviving family (compensation) pension prepaid
lump sump paid to eligible is less than 1,000 days of the basic daily benefits
payment amount*Submission of materials other than those listed may be

Statute of Limitations on Claims
If claims for surviving Family (compensation) lumps sums are not made within 5 years of the day
following the day the recipient died, claim rights will lapse due to the statute of limitations aswith surviving Family (compensation) pension

28

Surviving Family (Compensation) Pension
Prepaid Lump Sum
Surviving family’s eligible to receive Surviving Family (Compensation) Pension can opt to receivea 1 time lump sum prepayment instead. In addition, individuals who stopped receiving pension
payments because they were under pension age, can receive prepayments.

Benefit Details
Prepaid lump sum amounts can be selected from amount 200 days, 400 days, 600 days, 800 days and1000 days of basic daily benefits amount.
If a prepaid lump sum is paid, the monthly Surviving Family (Compensation) Pension payments willcease until such time as they have reached the amount of the prepaid lump sum (lump sums which
exceed a single year’s portion will be reduced by the amount of 5 % simple interest a year).

Claim Procedures
When making a claim for a Surviving Family (Compensation) Pension, in principle a “Surviving
Family Pension/ Surviving Family Pension Prepaid Lump Sum Claims Form” (Pension Application
Form No. 1) should be submitted together with the claim for Surviving Family (Compensation)
Pension to the chief of the relevant labour standards inspection office. However, a claim can bemade even after receiving Surviving Family (Compensation) Pension payments if the claim is madewithin one year of the day following receipt of the pension payment determination notice. In thissituation, the claim should be for an amount within the scope of an amount where the already paid
amount of the pension is subtracted from 1000 days of the basic daily benefits payment amount

Statute of limitation
If claims for Surviving Family (Compensation) Pension Prepaid Lump Sum are notmade within 2 years of the day following the day the victim died, claim rights will
lapse due to the statute of limitations.

29Surviving Family (Compensation) Pension
Recipient Changes
If the eligible recipient of surviving family (compensation) pension becomes ineligible to receive
the benefits for the following reasons, the payment of the benefits will more to the next survivingfamily member in order of priority.
(1) The recipient dies
(2) The recipient weds (For those who have not submitted a marriage registration but lived in amarriage relationship with the deceased)(3) If the recipient is adopted by someone other than a direct relation (Including situations where
no registration is filed but the recipient lives in situation equivalent to being adopted)(4) If the recipient’s position as a member of the family of the deceased worker ends due todivorce, etc.
(5) If the recipient is a child, grandchild or sibling and reaches the first March 31St after theyturn 18 years old (excluding those who have a regular disability from the time the worker died)(6) The need for assistance for the recipient (a husband, child, parent, grandchild, grandparent or
sibling with certain disability) does not exist any more.

Claim Procedures
Submit a Surviving Family Compensation Pension/Surviving Family Pension Payment Claims
Form (Form No. 13) to the chief of the relevant labour standards inspection office.
Application for provision of surviving Family special pension should, in principle, be made at thesame time using the same form.
●Materials required when submitting
Situation

Attachments
Family register certified copy or extract or other materials which
certify the relationship between the claimant and other qualified
recipients whose livelihood is the same as the claimant showing
the relationship with the deceased worker

Must be attached in all case

If the claimant or another qualified recipient whose livelihood is the same as M edical certificate or other materials which certify the relevant
the claimant is a qualified recipient because of regular disabilities
person still suffers from the disability after the worker's deathIf any of the qualified recipients' livelihoods was tied to that of the deceased
M aterials proving the relationship and circumstances
worker's*Submission of materials other than those listed may be required.

30

Funeral Expenses (Funeral Rites Benefits)
Funeral expenses (Funeral Rites Benefits) are not necessarily available only to surviving family, but
generally reserved for surviving family who hold a funeral for the deceased.
If there is no surviving family to hold a funeral but a company funeral is held by the deceased’s
company instead, the funeral expenses (Funeral Rites Benefits) can be paid to the company

Benefit Details
Funeral expenses (Funeral Rites Benefits) amounts are 315,000 yen plus 30 days of the basic daily
benefits payment amount. however if this amount is less than 60 days of the basic daily benefits
payment amount, an amount equal to 60 days of the basic daily benefits payment amount will be
provided.

Claim Procedures
Submit a Funeral Expense Claims Form (Form No. 16) or a Funeral Rites Benefits Claims Form
(Form No. 16-10) to the chief of the relevant labour standards inspection office.
● Materials required when submitting
Death certificate, postmortem certificate, autopsy report, or certificate of details of such, or othermaterials which certify the circumstances and date of the worker's death.
(If the materials have already been submitted together with a surviving family (compensation)
allowance claims form, they are not needed)

Statute of Limitations on Claims
If claims for Funeral Expenses (Funeral Rites Benefits) are not made within 2 years of the day
following the day the worker died, claim rights will lapse due to the statute of limitations.

31

Nursing Care (Compensation)
療養（補償）給付について
Benefits
All class 1recipients of Disability (Compensation) Pension and class 2
recipients who have mental, nerve or thoracoabdominal organ
disabilities and who are already receiving nursing care can receive
Nursing Care Compensation Benefits (for employment injury) or
Nursing Care Benefits (for commuting injury).

Payment Conditions
1 Must have a regular disability.
Nursing care (compensation) benefits are divided into those who require constant nursing care andthose who require on call nursing care according to the severity of disabilities. The disability
conditions for constant nursing care and on call nursing care are as follows.
Detailed Disability Conditions of Relavent Person

Constant Nursing Care

On Call Nursing Care

① person with nervous system or thoracoabdominal organ disabilities and are in acondition which requires constant nursing (Disability class 1 category 3 and 4, injury
and illness class 1 category 1 and 2)②
・Those who have lost sight in both eyes in addition to other class 1 orclass 2 disabilities,injuries or illness
・Those who have lost both upper or lower limbs and require care
Others who require the same degree of nursing care as those in ①

① Victims with nervous system or thoracoabdominal organ disabilities and are in acondition which requires on call nursing （Disability class 2 category 2-2 and 2-3, injury
and illness class 2 category 1 and 2)② Those who are disability class 1 or equivilent but do not require constant nursingcare

2 Already receiving nursing careIf currently receiving nursing care from a private sector for-profit nursing service or from family,
friends or acquaintances.
3 Not currently hospitalized in a hospital or a clinic
4 Not currently admitted to an elderly healthcare facility, disability support center (limited only tothose cases receiving assisted living care), special elderly nursing home or special nursing home foratomic bomb victims.
If admitted to one of these facilities, it is considered that the victim is receiving sufficient care at thefacility and is thus not eligible.
32

Payment Conditions
Nursing Care (Compensation) Benefits payment amounts are as follows (as of April 1, 2013).

（１） For constant nursing care
①If not receiving nursing care from family, friends or acquaintances, the amount paid for
nursing care expenses will be provided (with a maximum limit of 104,290 yen).
②If receiving nursing care from family, friends or acquaintances:
I. If no expenses are paid for nursing care, a flat rate of 56,600 yen will be paid.
II. If expenses are paid for nursing care and are under a total of 56,600 yen, a flat rate of
56,600 yen will be paid.
III. If expenses are paid for nursing care, and are over 56,600 yen, that amount will be paid(with a maximum limit of 104,290 yen).

（２）For on call nursing① If not receiving nursing care from family, friends or acquaintances, the amount paid for
nursing care expenses will be provided (with an maximum limit of 52,150 yen).
② If receiving nursing care from family, friends or acquaintances:
I. If no expenses are paid for nursing care, a flat rate of 28,300 yen will be paid.
II. If expenses are paid for nursing care and are under a total of 28,300 yen, a flat rate of
28,300 yen will be paid.
III. If expenses are paid for nursing care, and are over 28,300 yen, that amount will be paid(with a maximum limit of 52,150 yen).
If nursing care begins part way through the month① If paid nursing care begins part way through the month →Nursing care expenses will be paid up to the maximum amount.
② If unpaid nursing care by family etc. begins part way through the month →No payment will be made for the concerned month.
(Ex.) In a case where unpaid nursing care by family etc. is started in October of the year
No payment is made during this period
Start

October

A flat rate is paid for this period

November

Even in this situation, in the “Claims Month” field on the claims form the date that nursing
care started should be noted (The month would be October in this example).

33

Claim Procedures
When making a claim for nursing care (compensation) benefits, submit a Nursing Care
Compensation Payment・Nursing Care Payment Claims Form (Form No. 16-2-2) to the chiefof the relevant labour standards inspection office.
● Materials required when submitting

Situation

Detailed Disability Conditions of Relavent Victim

Must be attached in all cases

Medical certificate from doctor or dentist

If paying nursing care expenses

Materials which certify the number of days of nursing
care and expenses※ Submission of materials other than those listed may be required.

Those receiving Injury and Disease (Compensation) pensions and those with class 1 category 3 or 4
or class 2 category 2-2 or 2-3 do not need to attach a medical certificate.
A medical certificate does not need to be attached from the second submission of a nursing care(compensation) claims form onward. Claims for nursing care (compensation) benefits are handled in 1
month units, however up to 3 months worth of claims can be submitted at one time.

Statute of Limitations on Claims
If claims for nursing care (compensation) benefits are not made within 2 years of the first dayof the month following the month nursing care was received, claim rights will lapse due to thestatute of limitations.

34

Examples for Filling Out Various Claims Forms

１． Medical Treatment Benefits Claims Form (Form No. 5)
２． Medical Treatment Expense Payment Claims Form (Form No. 7)
３. Temporary Absence from Work Compensation Payment Claims Form (Form No. 8)
４．Disability Compensation Payment Claims Form (Form No. 10)
５. Surviving Family Compensation Lump Sum Payment Claims Form (Form No. 15)
６．Surviving Family Compensation Pension Payment Claims Form (Form No. 12)
７． Funeral Expense Claims Form (Form No. 16)
８．Nursing Care Compensation Payment Claims Form (Form No. 16-2-2)

35

Medical Treatment Benefits Claims Form (Form No. 5)(Example)
Use form 16-3 forcommuting injury

Have this filled out by
your work place if you
are uncertain.

Fill out in the orderof era name, year andmonth.
Industrial Accident Compensation Insurance number

Birth dayEnter “1” if you
are a male or “3”
if you are afemale.

Era name： 5 forShowa, 7 for Heisei

date of injury or attack

Name(Katakana)
Name

Leave a space between
first and last names andwrite names in katakana.

Age

Address

Time of injury or attack
Am

Fill out the name and job of
the person who confirmed
the circumstances of theaccident.

Pm
zip code

position

Industrial Category

Name

The cause of the accident and the outback situation① Where② What were the circumstances③ What type of work were you
carrying out at the time
④ What was the cause⑤ Clarify what type of accident
occurred*Employer
Certification Field

The chief of the Labour
Standards Inspection Office
Name ofhospital

zip code

Claimant’s

Telephone

Address
Name
Sign

Seal is not required if filled
out by the claimant.

To be filled out byclaimant

To be filled out
by company

36*Consult with the supervising
institution when submitting if
certification from the company
cannot be obtained

Medical Treatment Expense Payment Claims Form (Form No. 7 (1)(front））(Example)
Use form 16-5-1 forcommuting injury
Have this filled out by yourwork place if you are
uncertain

Workers’ compensation insurance number

Birth dayEnter “1” if you
are a male or“3” if you are afemaledate of injury or attack

Age

Name

Fill out in the order of
era name, year andmonth.
Era name： 5 for Showa,
7 for Heisei

Leave a space between
first and last names andwrite names in katakana

zip code

Address
Enter “1” forOrdinary
Savings Accounts and“2” for Current
Accounts.

Kind ofdepositName of financial
Institution

account number

The full name of the account holder of a title deed
Filling out ㉒㉓㉕㉖, the bankname and account holder in the left
column are necessary only when
opening a new account or changing
the reported account,

Branch nameAccount holder*Employer
Certification Field*Since the second claim, filling out is not necessary if
you have already quit the job

Certification by doctor or dentist

Medicaldetails

Period: year month day – year month day ,total days , net treatment days
I prove that about the person ⑨, the fact is as thesection (イ)、(ロ)、(ハ) and (ニ).

The site and nameof injury/disease

Date
To be filled out
byAddress
Name
medical institution
Doctor in charge

Zip code

Summary of the
Hospitalcourse ofor clinic
injury/disease
Year month day cured / continued / changed
the doctor / stop / death

Telephoneseal

Details of the treatment and amount (as the details on the back)Nursing charges
Transportation costs
Medical expenses except theabove
Reason why supply ofrecuperation is not received

Amount of cost that requires it to recuperate

Date of application

zip code
Address

Claimant’s

Name
The chief of the Labour
Standards Inspection Office

To be filled out byclaimant

To be filled out by
medical institution

Telephone

Sign

Seal is not required if filled
out by the claimant.

37

To be filled out
by company*Consult with the supervising
institution when submitting if
certification from the company cannot
be obtained

Medical Treatment Expense Payment
Claims Form (Form No. 7(1) （back））Example
Time of injury or attack
Am
Pm

Name and address inworkplace

Job

Fill out the name and job of
the person who confirmed
the circumstances of theaccident.

Name

The cause of the accident and the outback situation

First visit outside hours / day off / midnight
Second visit: outpatient
×timesfollow-up addition ×times
outpatient addition ×times
outside hours
×timesday off×timesmidnight
×timesInstruction
Home care：house callnight
emergency / midnight
visiting careothermedicine

First visit:
Second visit:
Instruction:
Other:
Food (basic )yen × days
yen × days
yen × days
Subtotal
②

times
times
times
times
times

① Where② What were the circumstances③ What type of work were you
carrying out at the time
④ What was the cause⑤ Clarify what type of accident
occurred

yen
yen
yen

times
times

yen
yen
yen
yen
Summary

Dosage: internal use medicine
units
dispensing ×times
at one dose medicine
units
external use medicine
units
dispensing ×times
treatment
×timesnarcotic and toxicant
times
basic dispensing fee

To be filled out by
Injection: subcutaneous and intramuscular times
intravenousmedical institution
times
other
Treatment:
medicine

times（Details of times
the treatment and theamount ）Operation anesthesia:
times
medicine
Check :

times

medicine
Image diagnosis:

medicine
Other: prescription
medicine

times
times

Hospital stay: date of admission
Hospital / clinic / cloth:
basic hospital fee / addition
×days
×days
×days
×days
×days
Specified hospital fee / other
Subtotal

points ①

yen

Total ①+②38

yen

Temporary Absence from Work Compensation Payment Claims Form (Form No. 8)
Use form 16-6 forcommuting injury

Enter “1” if you are amale or“3” if you are a female

Have this filled out by yourwork place if you are
uncertain

Industrial Accident Compensation insurance number

Birthdaydate of injury or attack

Fill out in the orderof era name, year andmonth.
Era name： 5 forShowa, 7 for Heisei

Leave a space between firstand last names and write
names in katakana
zip code
Name
Fill out the period
you did not work
because of treatment(⑳) and the days you
did not receive wage(㉑) in the period

Address

Enter “1” for Ordinary
Savings Accounts and“2” for Current
Accounts.

Period when it was not able to work because ofrecuperation

Days on day when pay was notreceived
Name of financial
Institution

Kind ofdepositAccount number

Branch name

The full name of the account holder

Filling out ㉒㉓㉕㉖, the bankname and account holder in the left
column are necessary only when
opening a new account or changing
the reported account,

Account holder

Employer
Certification Field*Since the second claim, filling out is not necessary if
you have already quit the job
Certification by the doctor in charge

To be filled out by
medical institution

The site and nameof injury/disease

Treatment period year month day – year month day , days, net treatment days

Course of
injury/disease

Current treatment

date cured / death / changed the doctor / stop / continued

The period working was impossible due to treatment:days ofdays from year month day to year month day
I prove that about the person ⑫, the fact is as the section from 28 to 31
TelephoneDate
Hospital
Addressor Clinic
Name
Name of the doctor in charge
zip code

Date of application
Claimant’s

Seal
Telephone

Address
Name

Sign

Seal is not required if filled out
by the claimant

To be filled out byclaimant

To be filled out
by medical
institution

To be filled out
by company

39* Consult with the supervising institution
when submitting if certification from thecompany cannot be obtained.

Disability Compensation Payment Claims Form （Form 10）(Example)
Circle “男” formale or “女”forfemaleUse form 16-7 forcommuting injury
Name(Katakana)
Name

Have this filled out by yourwork place if you are
uncertain

date of injury or attack

Age

Birthday
Address(Katakana)Address

Worker’s

Industrial Accident Compensation
insurance number

date of wound recovered

Average wages

The cause of the disaster and theoutback situation
Total of special salary
In one year

Individual pension number
Employees' pension
insurance etc

Clarify the location where theaccident occurred, the work being
carried out and the conditions atthat time

Kind of pension
Grade of disability
Amount of provided pension
Date to have been provided
Pension code of annuity bond of welfare annuity
Jurisdiction pension office etc

Only fill out this section if
your receive pension
payments from the welfare
pension insurance system etc.
for the same injury, disease
etc.

Employer
Certification Field
Part and symptom of existing trouble
Name of appended document

Branch nameName of financial institution

Sign number of bankbook
Name of postal savings (katakana)Name of postal savings

Financial
institution or post
office wheretransfer ofpension is hoped

Address
Sign number of bankbook
zip code

Claimant’sDate of application

Telephone

AddressName

Financial institution or post office wheretransfer of pension is hoped

Branch name

Sign

Account number
Nominee

Seal is not required if filled out
by the claimant

To be filled out byclaimant

To be filled out
by company

40

Surviving Family Compensation Pension Payment Claims Form
（Form 12）(Example)
Use form 16-9 forcommuting injury.

Circle “男” formale or “女”forfemaleName(Katakana)NameWorker’s

Industrial Accident Compensation
insurance number
Have this filled out
by the work place if you are
uncertain of the number

date of injury or attack

BirthdayAge

Industrial categorydate of wound recovered

Average wages

The cause of the disaster and theoutback situation

Clarify the location where
the accident occurred, thework being carried out andthe conditions at that time

Relation with thereceipt of employee
pension insurance etc.

Universal pension number andpension code of pension
certificate of employee
pension

Date

Date

The local social insurance office

Employer
Certification Field
NameEnter theclaimant’s name,date of birth,address, relationshipwith victim, andwhether or not they
suffer from any
disabilities.

Enter the names ofany survivingfamily other thanthe claimant who
may receive
surviving family
compensation
pension payments

The start date when
pension was issued

The amount of pension issuedyenBirthday

Address

Claimant’s

Only fill out thissection if yourreceive pension
payments fromthe welfare
pension insurance
system etc. forthe same injury,
disease etc.

Total of special salary

In one year
The deceased worker’s universal pension number
The date when the deceased
and pension code of pension certificate of employee
worker became eligible to bepensioncovered by the insurance
The type of pension issued regarding to the relevant death

Name

Birthday

Address

RelationtoworkerPresenceof
handicap

RelationtoworkerPresenceof
handicap

Circle “ある” if
the person has
any disabilities
and “ない” ifthey do not haveany disabilities.

Is theperson’s
livelihoodtied to that oftheclaimant’s?

Name of appended document
Financial
institution or post
office wheretransfer ofpension is hoped

Name of financial institution
Sign number of bankbook

Branch name

If yes, circle“いる” and if
no, circle “いない”.

Name of postal savings
Address
Sign number of bankbook
A zip code

Date of application

Claimant’s

Telephone

Address
Sign

Name

Financial institution or post office where transfer of pension is hoped

Name

To be filled out byclaimant

To be filled out
by company

BranchnameAccount number
Nominee

Seal is not required if filled out
by the claimant

41

Surviving Family Compensation Lump Sum Payment Claims
Form （Form 15）(Example)
Circle “男” formale or “女”forfemaleUse form 16-9 forcommuting injury.
Name(Katakana)NameWorker’s

Industrial Accident Compensation
insurance number

date of injury or attack

BirthdayAge

Industrial category

Have this filled out by yourwork place if you are
uncertain

date of wound recovered

Average wages

The cause of the disaster and theoutback situation

Total of special salary
In one year

Clarify the location where
the accident occurred, thework being carried out andthe conditions at that time

Employer Certification
Field
Name

RelationtoworkerAddress

Claimant’s

Enter the claimant’s name,date of birth, address,
relationship with victim,
and whether or not they
suffer from any disabilities.

BirthdayName of appended document

A zip code
Date of application

Telephone

Claimant’sAddress
Sign
Name

Financial institution or post office where transfer of pension is hoped
Branchname

Name

To be filled out byclaimant

To be filled out
by company

Account number
Nominee

Seal is not required if filled out
by the claimant

42

Funeral Expense Claims Form （Form 16）(Example)
Use form 16-10 for
commuting injury.

Circle “男” formale or “女”forfemaleName(katakana)
Claimant’s

Industrial Accident Compensation
insurance number

Address

Relation to worker

Name(Katakana)Worker’s

BirthdayAgedate of injury or attack

Industrial category
Address

date of death

The cause of the disaster and theoutback situation

Clarify the location where
the accident occurred, thework being carried out andthe conditions at that time

Average wages

Employer Certification
Field
Name of appended document

A zip code

Telephone

Date of application
Claimant’sAddress
Sign
Name

Financial institution where transfer is hoped
Account number
Branchname

Name

To be filled out byclaimant

To be filled out
by company

Nominee

Seal is not required if filled out
by the claimant

43

Nursing Care Compensation Payment Claims Form (Form No. 16 - 2-2)
(Example)
For Employment Injury
circle “介護補償給付”(Nursing Care Compensation
Payment ) and for commuting
injury circle“介護給付” (nursing payments).

Check the type of
pension being
received and notethe class

Wound

BirthdayWorker’s

If receiving annuity
bonds, note theannuity bond number.

class

Physicalhandicap

Number of annuity bondName(Katakana)Name

Address
Days

Years of object

Amount expended as costthat requires it to nurse
Enter the number ofdays for which
payment was madeand nursing carereceived

Write the date in“era”, “year”,“month” order.(TheHeisei era is number
7)

Financial institution where transfer is hoped

Only fill out items ㉘-㉛
and the financial
institution name andaccount holder namefields when registering a
new account or changing
an existing registeredaccount.

TypeOf
depositAccount
holderBranchnameName

Account number

Account holder(Katakana)
Account holder(Continuation)
Address

Home Facilities
etc
Person engaged in nursing

If care was received
at home, circle “イ”, if care wasreceived at a facility,
etc., circle “ロ”.
Enter the name, date ofbirth and relationship of
the person who provided
nursing care, the period
during which care wasprovided (the first and lastdays care was provided)
and the number of days
care was provided. For
class “ハ” and “ニ”, thename, date of birth andrelationship do not need to
be entered

Name

BirthdayName

Nursing period anddays

division

RelationshipIf the person who
provided care is afamily, circle “イ”, if
they are a friend or
acquaintance, circle“ロ”, if they are anurse or domestic
helper, circle “ハ”
and if they are facility
staff, circle “二”.

Appended
document
A zip code

Telephone

AddressSign

Name
It states it concerning the fact of nursing

Name

Address

44

Name

Sign

TelephoneEnter the address, name and telephone number of the person who provided care
Address

Seal is not required if
filled out by theclaimant
Telephone

Claims Forms and Submission Points for EachType of Insurance benefits
Benefit Type

Employment
or Cmmuting

Employment
InjuryMedical(Compensation)
Benefits
Industrial
Accident

Temporary Absencefrom Work(Compensation)
Benefits

Disability(Compensation)
Benefits

Funeral Expenses(Funeral Rites
Benefits )Nursing Care(Compensation)
Benefits

Medical Treatment Benefits Claims
Form for Medical Compensation
Benefits

Form
No.
No.5

Commuting Medical Treatment Benefits Claims
InjuryForm for Medical Treatment Benefits

No.16-3

Employment
InjuryTreatment Expense Claims Form for
Medical Compensation Benefits

No.7

CommutingInjuryTreatment Expense Claims Form for
Medical Treatment Benefits

No.16-5

Absence from Work Compensation
Payment Claims Form

No.8

Absence from Work Payment Claims
Form

No.16-6

Disability Compensation Payment
Claims Form

No.10

Disability Payment Claims Form

No.16-7

Surviving Family Compensation
Pension Payment Claims Form

No.12

CommutingInjurySurviving Family Pension Payment
Claims Form

No.16-8

Employment
InjurySurviving Family Compensation
Lump Sum Payment Claims Form

No.15

CommutingInjurySurviving Family Lump Sum
Payment Claims Form

No.16-9

Employment
InjuryFuneral Expense Claims Form

No.16

Employment
InjuryCommutingInjuryEmployment
InjuryCommutingInjuryEmployment
InjurySurviving
Family(Compensation)
Benefits

Claims Form

CommutingFuneral Rites Benefits Claims Form
InjuryNo.16-10

Nursing Care Compensation
Payment ・Nursing Care Payment
Claims Form

No.16-6

45

Submit to
The chief of the relevant Labour
Standards Inspection Office Via
Hospital, Pharmacy, etc.

The relevant
Labour Standards
Inspection Office（March 2014）