1Maternity Allowance
HealthInsurance Payment Request
Information on Insured (Applicant)Symbol(Aligned to theright)

NameDate of birth□ Showa

3 4 5 6 7

1 0 0 1

3Entered by insured (applicant)NumberInsurance Card

2YYMMDD0 2 0 4 1 5

 Heisei□Kenpo BOSCH(Postal code

Address
Phone No.

(Daytime contact)

TEL

224－090 ( 12348501)

Kanagawa

To DoFu Ken) 5678

Yokohamashi Tsuzukiku
Ushikubo 3-9-1□
 I delegate the submission of this Request to Employer. (In case of delegation, put a check in the box.)

Designated Bank Transfer A/C

Name offinancialinstitution

SMBC Shintaku

Deposit type1

Shinkin
CreditBank
Union
AgriculturalFishery
CoopCoopBankOthers

1. Ordinary 3. Separate
2. Current(A/C No.

4. Call

Yokohama

HeadOffice

BranchLocal office)HQ.

1 0 0 1 3 4Sub-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.)K e n p oAccount name

Receiving Agent Section

Insured(Applicant)B o s c hI hereby authorize the following agent to receive benefits based on
this Request.

1. Applicant

1

2. Agent

Reiwa YY MM DD

Name

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

Agent
Agent

A/Ccategory－) TEL()

Address(Account holder)(Account holder)

Relationshipbetweenmandator andagent

Name

A form “Entered by insured (applicant)/doctor/midwife” 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 BoschHealth 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.

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Maternity Allowance
HealthInsurance Payment Request
Application Detail

2. In the case of “Request before birth,” enter the expected date ofdelivery.
In the case of “Request after birth,” enter the expected and actual
dates of delivery.

1. Request before birth

Reiwa YY MM DD

XX 04 21

Date of delivery

Reiwa YY MM DD

XX 04 22

From Reiwa YY MM DD

XX 03 11
XX 06 17

To Reiwa YY MM DD

299 days

1. Yes2. No

Single birth Multiple birth

5. Number of newborn

2. Request after birth

Expected date of delivery

3. Period of leave due to childbirth (application period)

4. Did you receive any remuneration for the above leave period due
to childbirth (application period)?
Or will you receive it in the future?

3Entered by insured (applicant)/doctor/midwife

2

1. Is this maternity allowance requested before or after childbirth?

2(chldn.)Entered by doctor/midwife

Name of persongiving birth
Expected dateof delivery
Number ofnewborn

Date of delivery

Reiwa YY MM DD
Single birthMultiple birth (chldn.)

I hereby certify that there is no discrepancy as described above.

Reiwa YY MM DD

Live birth or stillbirthLive birth

Stillborn (weeks pregnant)Reiwa YY MM DD

Location of medical institution
Name of medical institution
TEL

Name of doctor/midwife()

When correcting the information entered, please cross out the corrected part with a double line and provide the correct
information and the name (signature) of certifier.

□ 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 Employer” continues on page 3. ->>>

In case you need, you can submit this payment request “before birth” and “after birth”
separately. In this case, please obtain a certificate of employer each time. If a certificateof doctor/midwife was entered for “before birth” submission and we can confirm thedelivery date and so on, you do not have to obtain it for “after birth” submission.
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Maternity Allowance
HealthInsurance Payment Request

2

3

Entered by Employer

Please enter the attendance and wage payment status for the wage calculation period, including non-working period.
Certified by Employer

Name ofinsured
For attendance status, indicate “○” for attendance, “△” for paid leave, “P” for public holiday, and “/” for absent.

Attendance

Paidleave

Reiwa YY MM

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Ttl.

days

days

Reiwa YY MM

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

Ttl.

days

days

Reiwa YY MM

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

Ttl.

days

days

Reiwa YY MM

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

Ttl.

days

days

Reiwa YY MM

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

Ttl.

daysdays

Did you (will you) receive anywages for the above period?

□ Yes□ No□ Monthly wage
□ Hourly wage
□ Daily wage
Type of salary□ Commission□ Daily-based monthly wage
□ Others

Wagecalculation

Closing
dateday□ Current

Date ofmonth
payment □ Nextday

monthEnter the wages incurred in a wage calculation period including the above period.
PeriodDetails of wages incurred (accrued)

For MM DD - MM DD

For MM DD - MM DD

For MM DD - MM DD

Amount paid on MM DDAmount paid on MM DD

Amount paid on MM DD

UnitPrice
Category
Base salary

Please enter the wage calculation
method (e.g., method of calculating
deductions for leave of absence).

If commuting allowance is paid for
multiple months and is not deducted
for leave of absence, for the purposeof calculating the deduction, fill in therelevant month even if it has alreadybeen paid.

Commutingallowance
Housing
allowance
Dependent
allowance
Overtime
allowance

yen forAllowance

For MMmonths- MM

Date ofpayment

Total

StaffnameReiwa YY MM DD

I hereby certify that there is no discrepancy as described above.
Location of business office
Name of business office
Name of Employer

TEL()

When correcting the information entered, please cross out the corrected part with a double line and provide the correct
information and the name (signature) of certifier.

Bosch Health Insurance Society

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