Health
Insurance

1Supplemental Injury and Payment
Sickness Benefits
Application[Extension]
Form234

Applicant Entry
Form

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)

Saitama

2-5-5 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 numberShinkin
BankMainbranchHigashimatsuyamaFishery
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゜I delegate the authority to receive benefits based on this application form tothe following agent:

2. Agent

Date: Reiwa (Y)/ (M)/ (D)Address: Same as the address under “Information
regarding the insured person (Applicant)”Name(〒-)

TEL()

Address

AgentAgent(Accountholder)(Account holder)

1. Applicant

1Relationshipbetween 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

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HealthInsurance
Application details

1)

1. Name of injury orillness

1

Supplemental Injury and Payment
Sickness Benefits
Application[Extension]
Form○○○○

3)

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

3

4

Applicant Entry
Form✓□ Heisei □ Reiwa

2. Date ofillness
onset orinjury2)

2

X / 12/ 1□ Heisei □ Reiwa (Y) / (M) / (D)□ Heisei □ Reiwa (Y) / (M) / (D)○○○○○○○○○○○○○○○○○○○○○○○○From✓
0 X 0 6 0 1

To0 X 0 6 3 0(□ 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)

Numberof days

30day(s)Fill in your job description even if you have retired.
Do NOT describe you 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 above
medical 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?

22-[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 the
injury 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

○○○○

Basic
PensionNumber

XXXX-XXXXXX

Pension
Code

Date ofinitialpayment□ Showa□ Heisei□ Reiwa (Y)/ (M)/ (D)Benefitamount3. (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. No

1. Yes
2. Pending
3. No

Name

BasicPension
NumberDate ofinitialpayment

3

yenPensionCode□ 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. 〉〉〉◆ After applying for “Disability employees’ Pension” or “Disability Benefits” and receiving
the “Pension Certificate” or “Notification of Pension Decision,” send a copy to Bosch
Health Insurance Society without delay.
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Bosch Health Insurance Society

HealthInsurance

1

Supplemental Injury and PaymentSickness Benefits
Application[Extension]Form234Employer
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 leave

X/ X

1/ 2/ 3/ 4P P
5 6/ -7 8/ 9/ 10
/ 11
P 12
P 13
/ 14/ 15/ 16/ 17/ 18
P 19
P 20/ 21
/ 22
/ 23/ 24
/ 25
P 26P 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

Reiwa

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

✓□ Monthly□ Yes

Wage type✓□ No□ Daily

Closingdate□ Hourly

Wagecalculation□ Commission□ Daily paid monthly

0 Day 0 DayDayDay

Last day ofthe month Day□ Current
Paymentmonthdate□ Followingmonth□ OtherDayDay✓25 Day

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

PeriodUnit
PriceCategory

Breakdown of accrued (future) wages

Basic salary

XXXXX

From

From MMM.DD.

toX/X
X/X

From 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.

X

Commutingallowance
Housingallowance

If commuting allowance is paid for
multiple months at once anddeductions are NOT made forabsences,
fill in the corresponding months even if
already paid in order to calculate
deductions.

Familyallowance
Overtime
allowance
Allowance

yen formonth(s)From MMM. to MMM.

Total

Payment date

X
Reiwa

Name ofcontact
person

X X XX//□□ □□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.
□□□□
Telephone049(XXX )XXXXIf you wish to correct any information you have entered, cross out the information to be corrected with a double line, and fill in thecorrect 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

3/4Field for the person in charge of medical treatment to provide an opinion

○○○○

(1)

Commencement
date for medicaltreatment
benefits(Date of initialconsultation)

Name of injury or (2)illness(3)

Periodrecognized as
unable to work
Length of
hospital stay

Actual days of
medical care(including length ofhospital stay)2

34

Medical Staff Entry
Form

Bosch Kempo

Name of patient

Date of illness
onset or injury

1

Supplemental Injury and Payment
Sickness Benefits
Application[Extension]
Form

HealthInsurance□ Illness onset

X /12/ 1Reiwa✓□ 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).

2Day

Circle the datesof medicalexaminations
andhospitalization.

X /12/ 1(2) □ Heisei □ Reiwa (Y)/ (M)/ (D)(3) □ Heisei □ Reiwa (Y)/ (M)/ (D)○○○○Cause ofillness onset orinjury

Forday(s) Other medical
hospital stay expenses

To Reiwa (Y)/ (M)/ (D)✓(1) □ Heisei □ Reiwa✓□ Health insurance□ Public funds (□ Self-paid □ Other)□ Recovered
Outcome □ Discontinued□ Carried forward□ Hospital transfer✓

6 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 operation Reiwa (Y)/ (M)/ (D)etc., during the above period.

○○○○○○○○○○○○○○○○○○○○
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.

○○○○○○○○○○○○○○○○○○○○

When dialysis isperformed or anartificial organ is
attached

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 / 7 / 22

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

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