Health
Insurance

1Injury and Sickness Benefits/ Payment
Supplemental Injury and Application
FormSickness Benefits

234

Insured Person Entry Form (ForApplicant)Please use double-sided printing to help simplify clerical duties.
Information regarding the insured person(Applicant)SymbolDate of Birth (MMM. DD, YYYY)

NumberInsurance card
(Fill in from the rightside)

1 0 0 1
ボッシュ(Furigana)Name□ Showa

2 3 4 5 60 1 1 1 2 0✓

□ Heisei

ケンポ

Bosch Kempo(〒355-TEL0493(AddressTelephone
number002822)

Saitama2-5-5 Yakyu-cho,Higashimatsuyama City0890)(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 accountCreditUnion

BankName of financial
institution

Saitama Resona

Agricultural
Cooperative
Other

1

Account type

1. Ordinary 3. Special
4. Deposit at
2. Currentnotice(Account number

Shinkin
BankMainbranchHigashimatsuyama

Fishery
Cooperative)

7 6 5 4 3 2 1

BranchLocal office
Headoffice

BranchofficeFill in from the left side.

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

ホ゛ ッシュ

Beneficiary agent field

Insured person(Applicant)Accountholder
category

ケンホ゜

2. Agent

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

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

TEL()

Address

AgentAgent(Accountholder)(Account holder)

1. Applicant1Relationshipbetween theDelegator andthe Agent(Furigana)Name“Applicant Entry Form” continues on page 2. 〉〉〉(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.

Bosch Health Insurance Society

2-5-5 Yakyu-cho, Higashimatsuyama City, 355-0028 Internal mail: Hig RBHI

1/4

HealthInsurance

Application details1)

1. Name of injury orillness

Injury and Sickness Benefits/ Payment
Supplemental Injury and Application
FormSickness Benefits

Clavicle fracture3)

2

3

4

Insured Person Entry Form (ForApplicant)✓□ Heisei □ Reiwa

2. Date ofillness
onset orinjury2)

3. Situation at the time of illness onset or injury for the relevant
injury or illness

1

X /12 / 1

□ Heisei □ Reiwa (Y) / (M) / (D)□ Heisei □ Reiwa (Y) / (M) / (D)Tripped over a stone while walking
on the sidewalk, and hit the groundfrom the right shoulder.
✓(□ Heisei □ Reiwa) (Y)/ (M)/ (D)4. Period of absence for medical treatment (application period)

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

0 X 1 2 0 1

To

0 X 0 1 1 5

Numberof days

46day(s)Do NOT describe the content of your work as “clerical worker.”
Instead provide specific details, such as “accounting affairs,”“automobile assembly,” or “programmer.”

Confirmation items

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

2

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

32-[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.

1. Yes

2. No

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 which
payment is being received (or the claim was filed).

1. Disability Employees’ Pension
2. Disability Benefits

Name ofinjury orillness

BasicPension
NumberDate ofinitialpayment

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.

1. Yes
2. Pending
3. NoPension
Code□ Showa□ Heisei□ Reiwa (Y)/ (M)/ (D)

1. Yes
2. Pending
3. No

3

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. 〉〉〉
Bosch Health Insurance Society

2/4HealthInsurance

1

Injury and Sickness Benefits/ Payment
Application
Supplemental Injury andForm
Sickness Benefits

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 unable
to work.

Information to be certified by the employer

Name of insured
personBosch Kempo

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

Attendance Paid leaveReiwa

X / 12

1P△△△△
2 3 4 5 6x P
7 P
8 9/ 1031 Total/ 11/ 12/ 13/ 14
P 15
P 16/ 17/ 18/ 19/ 20/ 21P 22P 23/ 24/ 25/ 26/ 27/ 28
P 29P 30P P

0 Day 4 Day

Reiwa

X/ 1P x6 /7 8/ 9/ 10/ 11P 12P 13/ 14/ 15/ 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total
1P P
2 P
3 P
4 50 Day

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□ Yes

Wage type□ No□ Daily

Closingdate□ Hourly

Wagecalculation□ Commission□ Daily paid monthly

DayDayLast day ofDaythe month□ Current
Paymentmonthdate□ Followingmonth□ Other0 Day✓

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

PeriodUnit
PriceCategory

Breakdown of accrued (future) wages

Basic salary

200,000

Commutingallowance
Housing
allowance

15,000From 12 / 1
to12 / 31

From 1 / 1
to1 / 15

Amount paid for MMM.
DD.

Amount paid for MMM.
DD.

MealAllowance

6,000

to MMM. DD.

Amount paid for MMM.
DD.

40,000000

15,00015,000100,000

Overtime allowance for
December is for overtime
worked on 12/1 - 31.

Familyallowance
Overtime
allowance

From MMM.DD.

0

Fill in the wage calculation method (absencededuction calculation method, etc.)

Basic salary absence deduction
200,000 yen ÷ 20 days × 16
days = 160,000 yen
No absence deduction for commuting
allowance

If the deduction start date differsfrom the absence start date, pleaseindicate that here.
If commuting allowance is paid for multiple
months at once and deductions are NOT
made for absences,
fill in the corresponding months even if alreadypaid in order to calculate deductions.

60,000 yen for 60month(s)From August to January
Total

281,000

155,000

Payment date

15,000Reiwa

X / 1 / 31

Name of theresponsiblepersonJuly 25□□ □□I certify that there are NO discrepancies in the information above.
Location of office
Name of office
Name of employer

1 -2 -3 ○○, Higashimatsuyama-city, Saitama△△△△ Co., Ltd.
□□□□
Telephone

049(XXX )XXXX

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

3/4Injury and Sickness Benefits/ Payment
Supplemental Injury and Application
FormSickness Benefits

HealthInsurance

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

Clavicle fracture(1)

Name of injury or (2)illness(3)

Periodrecognized as
unable to work
Length ofhospital stay

Actual days of
medical care(including length ofhospital stay)

2

3

4

Medical Staff Entry Form

Bosch Kempo

Name of patient

Date of illness
onset or injury

1ReiwaCommencement
date for medicaltreatment
benefits(Date of initialconsultation)□ Illness onset✓X/ 12 / 1□ Injury

Fill in the period and the number of days during which theemployee was recognized as being unable to work due to
medical treatment, NOT the treatment period. Also, fill in theperiod before the certification date.

From Reiwa (Y)/ (M)/ (D).

Cause ofillness onset orinjury

For

day(s) Other medical
Hospital stay
expenses

To Reiwa (Y)/ (M)/ (D)✓(1) □ Heisei □ Reiwa

X / 12 / 1(2) □ Heisei □ Reiwa (Y) / (M) / (D)(3) □ Heisei □ Reiwa (Y) / (M) / (D)Heavy blow to the rightshoulder✓□ Health insurance□ Public funds (□ Self-paid □ Other)□ Recovered
Outcome □ Discontinued□ Carried forward□ Hospital transfer✓

12 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
1 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 315Day

Circle the datesof medical
examinations
andhospitalization.

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 31Provide details on the major symptoms, progress, treatments, test results, and medical care guidance,
Date of operation Reiwa (Y)/ (M)/ (D)etc., during the above period.

First visit on December 1st for a fractured collarbone. Set
with a clavicle band.
Rest until the bone sets, and rehabilitation afterwards.

Date of discharge 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.

It was judged that the employee was unable to work due to the need for rest until thefractured bone set and to the need for rehabilitation thereafter.

When dialysis isperformed or anartificial organ isattached

Date dialysis wasperformed or an artificialorgan was attached□ Showa □ Heisei □ Reiwa(Y)/ (M)/ (D)Reiwa

Type ofartificialorgan, etc.

□ Colostomy □ Prosthetic joint□ Head prosthesis □ Cardiac pacemaker□ Kidney dialysis □ Others ( )X / 1 / 22

There are no discrepancies in the above information.
Location of the medical institution
Name of the medical institution
Name of the doctor

1 -2 -3, ○○, Moroyama-machi, Iruma-gun, Saitama△△△△ General Hospital□□□□Telephone 049

(XXX)

XXXX

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

4/4