イMessrs. Bosch Health Insurance Society,

Influenza Vaccination Subsidy Bill

※Voluntarily continued insured persons are requested to apply using “HealthService / Expense Application”.

【Applicant （Insured Person）】
InsurancecardSite Name

Date： (M)

Symbol

9999

No.

99999

【Vaccination Status】
Vaccinated Person’s
NameContact Phone No.

XX －XX／XX-XXXX-XXXX

XXXXPlease fill in even if the vaccinated person is an insured person only.
Relationship

Date of Vaccination

6.

7.
8.
9.

Name of Medical Institution

ExpenseKenpo TaroXX(M) 10 (D) 30,(Y) 2024○○病院

4,000Yen

Kenpo Hanako

XX(M) 10 (D) 30,(Y) 2024○○病院

4,000Yen

Kenpo IchiroXX(M) 10(D) 30 ,(Y) 2024○○病院

4,000Yen

(M)

(D)

,(Y)

Yen

(M)

(D)

,(Y)

Yen

(M)

(D)

,(Y)

Yen

【Conditions for Payment of Subsidy】
1.
2.
3.
4.
5.

Kenpo TaroXXXXX（CompanyName）

Unite Name

Insured
Person’s Name

11 (D) 15 ,(Y)2024

Total Amount

Object persons for subsidy: Shall be insured persons and their dependents
Object period: Every year from October 1 to January 31 of the following year
Number of applications: Once per person during the above period
Maximum amount of subsidy: ¥2,000/person for insured persons and dependents
Application method: The subsidy bill + an original receipt are requested to be presented tothis Health Insurance Society (The receipt cannot be returned.)※Vaccination receipts are ineligible for filling your final tax return.
Receipt entry items: Names of vaccinated persons, dates of vaccination, names of
medical institutions (seals), unit price per each vaccination, and clear definition that thecost is for “influenza vaccination”.
※We accept the receipt, even if it is of a receipt type slip, as long as above-mentioned
essential entry items are described and together with the receipt seal of the medical
institution. (All the descriptions shall be filled at the medical institution.)
Cases where you are not eligible for payment:① If you have received a group vaccination sponsored by each location② When vaccinated using Toshinkyo's influenza vaccination ticket
Limited only to those vaccinated in JapanThe vaccination period and submission deadline and so on will be announced separately.

12,000Yen

Bosch Health InsuranceSociety’s Entry Field（Please don’t fill in here.）

Determined
Amount ofAllowance

Yen【Where to send
Bosch Health Insurance Society (Hig-RBHI), Healthcare Promotion Section, Person in Charge of Subsidy
Application】【Recommended※Since an application document is equal to a security, the following sending method issending method】
recommended for prevention of losing it and for clarification of the responsible party.
① Sending by general mail: (Bosch Health Insurance Society, 2-5-5 Yakyucho, Higashimatsuyama City, 355-0028)
Please send it by registered mail or simple registered mail. However, please understand that we don’t
issue the document that certifies receipt.
② When “Internal Registered Mail Application” of Bosch internal mail can be used, please send it uponwriting the internal registered mail application with putting a � mark in the item of requesting “The receiptcertificate”. (When “Internal Registered Mail Application” cannot be used, please send it making use of theabove-mentioned method ①.)※ The sites or business offices which cannot utilize Bosch internal mail ② due to their remotelocations, are requested for cooperation to send the materials in bulk.

The information which you filled is collected for the purpose of our society to operate our service accurately and fairly according to Health Insurance Act and other related
notices of authorities. We don't use the personal information for other purposes than this purpose, nor provide it to the third parties. In the meanwhile, there may an
opportunity that we ask you for further details about the information which you filled and for the additional evidencing documents, if necessary. For further question on thehandling of the personal information or if you have a request for information disclosure and so on, please contact Bosch Health Insurance Society General Affairs Section(Phone 0493-22-0890). ※ As for the handling of personal information, please also see the home page, “Personal Information Protection Policy”. Revised on Apr, 2024