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HealthInsured Lump-sum Payment for Internal Payment Request
Balance Request
Entered by insured (applicant)Insurance Family Childbirth/Childcare
Information on Insured (Applicant)SymbolDate of birth

NumberInsurance Card
(Aligned to theright)

YY

Designated Bank Transfer A/CMMDD

HeadOffice

Branch□ Showa□ Heisei

Name(Postal codeAddress)－To DoFu KenPhone No.

(Daytime contact)

TEL()□ I delegate the submission of this Request to Employer. (In case of delegation, put a check in the box.)
Shinkin
CreditBankUnion
Agricultural
Fishery
CoopCoopBankName offinancial
institution

Others

1. Ordinary 3. Separate

Deposit type

2. Current

4. Call(Local office)

HQ.

A/C No.

Sub-office

Please enter aligned to the left.

▼ In katakana (Please leave one space between the first and last names, and enter symbols “゛” and “゜” as one
character.)

A/C
category

Account name

Receiving Agent Section

Insured(Applicant)I hereby authorize the following agent to receive benefits based on
this Request.

2. Agent

Reiwa YY MM DD

Name

Address: Same as the address in “Information on
insured (applicant)”(Postal code

Agent
Agent

1. Applicant－) TEL()

Address(Account holder)(Account holder)

Relationshipbetweenmandator andagent

Name□ This notification meets the requirement (i) or (ii). (Please put a check in the box.)(i) This Request is prepared by the applicant (insured).
(ii) The applicant confirmed that the contents are correct.

A form “Entered by insured (applicant)/doctor/ municipality mayor ” continues on page 2. ->>>
(R2.12)Name of submitting
Labor and Social
Security Attorney

Stamp of receipt date

The personal information you provide is gathered to help the Bosch Health Insurance Society undertake its operations fairly and inaccordance with the Health Insurance Act and relevant notifications. Under no circumstances will this personal information be provided toa third party or used for any purpose other than those stated above. In certain cases, we may contact you to seek clarification of details
you have provided, or, if necessary, ask you to provide additional supporting documentation. Please address all inquiries concerning thehandling of personal information, requests for disclosure of personal information, and so forth to the General Affairs Section of the Bosch
Health Insurance Society (telephone: 0493-22-0890).
*To find out more about how we handle personal information, please refer to the “Privacy Policy” on our website.

Bosch Health Insurance Society

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Insured Lump-sum Payment for Internal Payment Request
HealthEntered by applicant/doctor/mayor of
Insurance Family Childbirth/Childcare
Balance Request
municipality
Name of insured
Application Detail

1. Person who gavebirth

1. Insured

1-(i)In case of family member

2. Family member (dependent)
Date ofbirthName

2. Date of delivery

Reiwa

3. Live birth or stillbirth
3-(i)Number of newborn for“Live birth”

4. Medical institution,etc. delivered

1. Live birth

pers.

YY

2. StillbirthMMMMYYDDDD

3. Live birth / Stillbirth mixed

3-(ii)
Number of stillborn for“Stillbirth”

Name

pers.

3-(ii)-(1)Elapsed time of pregnancy inFullcase of "stillbirth”

weeks

Location

5. Person who gave birth

1. Yes Insured  Did you give birth within 6 months from the date of resignation?
 Family member  Has the baby been born within 6 months after joining our society?

Symbol/Number

5-(i)-(1)For the above childbirth, Lump-sum Payment forChildbirth/Childcare from Insurer in 5-(i) is:

1. Received / To be received

Certified bydoctor/midwife

Certified bymunicipality mayor(production only)

Certification Section (Fill in one of the boxes)

Name ofperson givingbirth

Date of delivery□ Single birth □ Multiple birth  (2. No

Name ofInsurer

5-(i)If “Yes,” enter the “Name of Insurer” and “Symbol/Number”.
 Insured  Insurer currently subscribed to Family member  Insurer subscribed prior to joining our society

Number ofnewborn□ Showa□ Heisei□ Reiwachldn.)

I hereby certify that there is no

Location of medical institution

discrepancy as described above.

Name of medical institution

Reiwa YY MM DD

Name of doctor/midwife

Live birthor stillbirth

Reiwa

YY

2. Not received

MMDD□ Live birth□ Stillbirth  (weeks pregnant)Name ofhead
householder

Registereddomicile
Name ofmother

Name ofnewborn

I hereby certify that there is nodiscrepancy as described above.
Reiwa YY MM DD

Name of municipality mayor

Date ofbirthReiwa

YYMMDD[In the case of submitting as Internal Payment Request]
Please obtain a certificate of birth by doctor/midwife, or a certificate of matters entered in the family register regarding the birth from municipality mayor.
In the case of stillborn, obtain a certificate issued only by doctor/midwife. Provided, however, that if the “Date of delivery” and “Number of newborn”
are indicated on the receipt/statement issued by the medical institution, etc., or if the “Date of stillborn” and the “Weeks pregnant” are indicated in thecase of stillbirth, certificates shall not be required.
[In the case of submitting as Balance Request]
A certificate of birth by doctor/midwife, or a certificate of matters entered in the family register regarding the birth from municipality mayor shall not berequired.

Bosch Health Insurance Society

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