Health
Insurance

1

Supplemental Injury and Payment
Sickness Benefits
Application[Extension]
Form

Information regarding the insured person(Applicant)Symbol2

3

4Applicant Entry
Form

Date of Birth (MMM. DD, YYYY)

NumberInsurance card
(Fill in from the rightside)□ Showa□ Heisei(Furigana)Name(〒-TEL()

Address
Telephonenumber)(Daytime contact)□ I delegate the authority to submit this application form to my employer. (Place a check mark in the box to delegate authority)

Designated transfer accountCreditUnionBank

Name of financialinstitutionAgricultural
Cooperative
Other

1. Ordinary 3. Special
4. Deposit at
2. Current
noticeAccount type(ShinkinBankMain
branchFishery
Cooperative

BranchLocal office
Headoffice)Account number

BranchofficeFill in from the left side.

▼Katakana (Leave one square between your first and last name. Please write diacritic marks (“, °) as one character. )Account
holdercategory

Account holder

Beneficiary agent field

Insured person(Applicant)

2. Agent

Date: Reiwa (Y)/ (M)/ (D)I delegate the authority to receive benefits based on this application form tothe following agent:

Address: Same as the address under “Information
regarding the insured person (Applicant)”Name(〒-)

TEL()

Address

AgentAgent(Accountholder)(Account holder)

1. Applicant

Relationshipbetween theDelegator andthe Agent(Furigana)Name◆ After applying for “Disability employees’ Pension” or “Disability Benefits” and receiving the “PensionCertificate” or “Notification of Pension Decision,” send a copy to Bosch Health Insurance Society without
delay.
(R2.12)Name of the social insurance
and labor consultant serving
as the agent in submitting thisform

Reception date stamp

The personal information you provide here is collected by the Health Insurance Society in order to conduct business operations in a fair and equitable manner,and in accordance with the Health Insurance Act and related government notices. We do NOT use personal information or provide it to third parties for any
other purpose. In addition, we may ask you about the information you have provided, and, if necessary, we may request that you submit evidentiary documents
separately. For inquiries or requests for disclosure regarding the handling of your personal information, contact the Bosch Health Insurance Society General
Affairs Division at 0493-22-0890.
*For details on the handling of personal information, also refer to the “Privacy Policy” on our website.

“Applicant Entry Form” continues on page 2. 〉〉〉
Bosch Health Insurance Society
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Application details

1)

1. Name of injury orillness

1

Supplemental Injury and PaymentSickness Benefits
Application[Extension]
Form

HealthInsurance

3)

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Applicant EntryForm□ Heisei □ Reiwa (Y) / (M) / (D)2. Date ofillness
onset orinjury2)2□ Heisei □ Reiwa (Y) / (M) / (D)□ Heisei □ Reiwa (Y) / (M) / (D)3. Situation at the time of illness onset or injury for the relevant
injury or illness(□ Heisei □ Reiwa) (Y)/ (M)/ (D)4. Period of absence for medical treatment (application period)

Numberof days

FromToday(s)5. Your job description (in detail)(In the case you are applying after retirement, provide details
on your job before retirement)

Confirmation items

1. Did you receive wages during the period of absence for the above
medical treatment (application period)?
Or will you receive wages in the future?

1. Yes

2. Are you receiving “Disability Employees’ Pension” or “DisabilityBenefits”?
If so, which one are you receiving?

1. Yes
2. Pending
3. No

2-[1] If you answered “Yes” or “Pending,” fill in the name of the
injury or illness that was (will be) the cause for your claim andyour Basic Pension Number.
If you answered “Pending,” fill in the name of the
injury or illness and your Basic Pension Number.

3. (Fill out this field if you have lost your eligibility for health insurance.)
Are you receiving a public pension due to old age or retirement?
If you are receiving a pension, fill in the name.
3-[1] If you answered “Yes” or “Pending,” fill in your Basic Pension
Number.
If you answered “Pending,” fill in the name of theinjury or illness and your Basic Pension Number.
4. Is this application for a period during which you received
compensation for an absence from work through workers’
compensation insurance?
4-[1] If you answered “Yes” or “Workers’ compensation pending,” fillin the Labor Standards Inspection Office through whichpayment is being received (or the claim was filed).

2. No

1. Disability Employees’ Pension
2. Disability Benefits

Name ofinjury orillness
Basic
PensionNumberDate ofinitialpayment

PensionCode□ Showa□ Heisei□ Reiwa (Y)/ (M)/ (D)

1. Yes
2. Pending
3. No

yen

Name

BasicPension
NumberDate ofinitialpayment

BenefitamountPensionCode□ Showa□ Heisei□ Reiwa (Y)/ (M)/ (D)

1. YesBenefitamountyen

3. No

2. Workers’ compensation pending
Labor Standards
Inspection Office□ This notification satisfies the requirements of [1] and [2] below. (Place a check in the box)
[1] This form was prepared by the applicant (the insured person).
[2] The applicant has verified that there are NO errors in the information contained herein.

“Employer Entry Form” continues on page 3. 〉〉〉
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Supplemental Injury and Payment
Sickness Benefits
Application[Extension]Form

234

Employer
Entry Form

Fill in the work status and wage payment status for the wage calculation period that includes the period the employee was unableto work.

Information to be certified by the employer

Name of insured
personIndicate the work status using [○ for attendance], [△ for paid leave], [P for public holidays], and [/ for absence].

Attendance Paid leave

Reiwa (Y)/ (M)1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total

Reiwa (Y)/ (M)1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total

Reiwa (Y)/ (M)1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total

Did (or will) the employee accrue
wages during the above period?

□ Monthly□ YesWage type□ No□ DailyDayDay

DayDayDay

Closingdate□ HourlyWagecalculation□ Commission□ Daily paid monthly

DayDay□ Current
Paymentmonthdate□ Followingmonth□ OtherDay

Fill in the wage accrual status for the wage calculation period that includes the above period.

PeriodUnit
Price
Category

From MMM.DD.

From MMM.DD.

From MMM.DD.

to MMM. DD.

to MMM. DD.

to MMM. DD.

Amount paid for MMM.
DD.

Amount paid for MMM.
DD.

Fill in the wage calculation method (absence
deduction calculation method, etc.)

Amount paid for MMM.
DD.

Breakdown of accrued (future) wages

Basic salaryCommutingallowance
Housing
allowance
Familyallowance
Overtime
allowance
Allowance

Total

Name of theresponsible
personReiwa (Y)/ (M)/ (D)I certify that there are NO discrepancies in the information above.
Location of office
Name of office
Name of employer
Telephone()

If you wish to correct any information you have entered, cross out the information to be corrected with a double line, and fill in the correct
information along with the name (signature) of the person who certified the changes.

“Medical Staff Entry Form” continues on page 4. 〉〉〉
Bosch Health Insurance Society

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Sickness Benefits
Application[Extension]
Form

HealthInsurance

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Medical Staff Entry
Form

Field for the person in charge of medical treatment to provide an opinion

Name of patient(1)

Commencement
date for medicaltreatment
benefits(Date of initialconsultation)

Name of injury or (2)illness(3)□ Heisei

Periodrecognized as
unable to work

From □ Heisei □ Reiwa (Y)/ (M)/ (D)Length of
hospital stay(Y)/ (M)/ (D)□ Reiwa□ Injury□ Heisei □ Reiwa (Y)/ (M)/ (D)Forday(s)From □ Heisei □ Reiwa (Y)/ (M)/ (D)For

day(s)To□ Heisei □ Reiwa (Y)/ (M)/ (D)Actual days of
medical care(including length of
hospital stay)Day(2) □ Heisei □ Reiwa (Y)/ (M)/ (D)(3) □ Heisei □ Reiwa (Y)/ (M)/ (D)□ Illness onset

Date of illness
onset or injuryTo(1) □ Heisei □ Reiwa (Y)/ (M)/ (D)Circle the datesof medical
examinations
andhospitalization.

Hospital stay

Cause ofillness onset orinjury

Other medicalexpenses□ Health insurance□ Public funds (□ Self-paid □ Other)□ RecoveredOutcome □ Discontinued□ Carried forward□ Hospital transfer

Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Provide details on the major symptoms, progress, treatments, test results, and medical care guidance, Date of operationetc., during the above period.

□ Heisei □ Reiwa (Y)/ (M)/ (D)Date of discharge□ Heisei □ Reiwa (Y)/ (M)/ (D)Based on the course of symptoms, describe any medical findings indicating that the patient was unable to engage in his/her regular occupation.

When dialysis isperformed or anartificial organ isattached

Date dialysis wasperformed or an artificialorgan was attached□ Showa □ Heisei □ Reiwa(Y)/ (M)/ (D)Type ofartificialorgan, etc.

□ Colostomy □ Prosthetic joint□ Head prosthesis □ Cardiac pacemaker□ Kidney dialysis □ Others ( )Reiwa (Y)/ (M)/ (D)There are no discrepancies in the above information.
Location of the medical institution
Name of the medical institution
Name of the doctor
Telephone()

If you wish to correct any information you have entered, cross out the information to be corrected with a double line, and fill in the correct
information along with the name (signature) of the person who certified the changes.

Bosch Health Insurance Society

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