Medical Care
Expenses
Application Form

Insured

HealthInsuranceFamily(payment of fullmedical costs upfront without
using healthinsurance, etc.)

12To be filled out by the insuredperson (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 60 1 1 1 2 0□ Heisei✓

ケンポ

Bosch Kempo(〒355-TEL0493(Address
Telephonenumber002822)

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. Current
notice(Account number

Shinkin
BankMainbranchHigashimatsuyamaFisheryCooperative)

7 6 5 4 3 2 1

BranchLocal office
HeadofficeBranch
officeFill 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)Account
holdercategory

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

1

Relationshipbetween 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 anyother 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

InsuredFamily

Name of theinsured person

Application details

1 Person receiving medicalcare(payment of fullmedical costs upfront without
using healthinsurance, etc.)

Medical CareExpenses
Application Form

1. The insured person

1Date of birthMM

3 Date of illness
onset or injury
occurring

08
MMDD,

YYYY

28 20XXDD,YYYYSuffered from childhood asthma that did not
fully disappear, and which recurred as anadult.
Asthma attacks occur when under stress.
Currently settled down

4 Cause of injury and progress(in detail)

NameLocation

Tokyoto Minatoku △ △67-8○○Hospital
5 Medical institution wheretreatment was received

NameFromMM

DDLocation

ToYYMMDD

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

Numberof days

1day(s)ToYY

Name of physician etc.
providing treatment

YY

0 8 2 8 X X
MMDD

YY

Numberof days

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

7 Expenses incurred fortreatment
8 Details of treatment

To be filled out by the insured
person (the applicant)

2. A dependent family member

Asthma attack

2 Name of injury or illness

6-(1) If hospitalized during
the above period, thedates in hospital2

Kenpo BOSCH

1-(1) If a family member, thenName
that person’s

6 Date(s) treatment wasreceived

15,600Yen

Examination, medication
1. I had not yet received my health insurance card as I had only just joined the company
2. Medical examination was unavoidable due to an emergency and I did not have my healthinsurance card with me

9 Information about the person
receiving treatment2

3. I used someone else’s health insurance card by mistake(Reason)
9. Other□✓ 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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