1Health
Overseas Medical
Insurance Care Expenses

2Application
To be filled out by the insured
Formperson (the applicant)Please use double-sided printing to help simplify clerical duties.
Information regarding the insured person(Applicant)SymbolDate of Birth (MM. DD, YYYY)

NumberInsurance card
(Fill in from the rightside)

1 0 0 1
ボッシュ(Furigana)Name□ Showa

2 3 4 5 6

1 1 2 0 0 1□ 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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HealthOverseas Medical Application
Insurance Care Expenses Form
Name of theinsured person

Application details

1 Person receiving medicalcare

2

To be filled out by the insuredperson (the applicant)Kenpo BOSCH
1. The insured person2

1-(1) If a family member, thenNamethat person’s
2 Name of injury or illness

4 Cause of injury and progress(in detail)1

2. A dependent family member

Mamoru BOSCH

Date of birth

Left ankle sprain

3 Date of illness
onset or injury
occurring0405 2016

MM08DD,

YYYY

28 20XX

MMDD,

YYYY

Twisted left ankle and fell over while coming offa slide at the park, spraining the ankle
Progress is good5 Medical institution wheretreatment was received
Name of country

NamePraxis Dr. ○○FromMM

6 Date(s) treatment wasreceived

6-(1) If hospitalized during
the above period, thedates in hospital

DDLocation

ToYYMMDD

FromMMDD□□ □□Name of physician etc.
providing treatment

YY

Numberof days

0 8 2 8 X X

1day(s)To

YYMMDD

YY

Numberof days

Please enter the amounts based day(s)on the attached original receipts.

7 Expenses incurred fortreatment
8 Details of treatment

70469 Stuttgart △△△NameGermany

Name of physician etc.
providing treatment

Location150( Euros ) Please enter the currency (e.g. U.S. dollars).

After examination, ointment was prescribed.
Are they currently planning to return to Japan? Or have they already returned?

✓□ 1. Yes

□ 2. No
Reasons for staying abroad

9 Information about the person
receiving treatment

 Period of travel ( August 22, 20XX to August 31, 20XX ) Purpose of travel
Reasons for travel

For travel□✓ This application satisfies the conditions of (1) or (2). (Please check the box ☑. )(1) This application was prepared by the insured person (the applicant him/herself).
(2) The applicant him/herself has checked that the content of the application is correct.

Bosch Health Insurance Society

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