Health Insurance

Dependent Application Record

Please make sure to read and agree to the items below when filling out the Dependent Application Record before
applying for a dependent.
If any corrections are made to the items herein, please use two lines to cross out the mistake and affix a revision seal
where the correction was made.
(This record does not need to be submitted for dependents who are a child by birth or a child in junior high school or younger.)● Regarding Dependents
The mere fact of being a family member does not qualify someone to be a dependent for health insurance purposes. The individual must fulfill
certain requirements, such as mainly relying on the insured person’s ability to continually maintain and support their livelihood as a dependent.

● Standards for Certification of Dependents
The Western Digital Technologies Health Insurance Association comprehensively reviews the items below to determine whether a person
qualifies as a dependent.
(1) The family applicant falls under the scope of dependents defined by the Health Insurance Act(2)

The insured person is undeniably the primary provider of economic support for the family member (provides at least half of their livingexpenses)(3)

There is no other person with a higher priority obligation to support the dependent as well as reasons that make support of the family
member unavoidable for the insured person*The person with the higher obligation to support the dependent is the father in cases when the mother is applying to become thedependent(4) The insured person has the economic ability to provide ongoing support to the family member(5) The annual income of the family member applying to become a dependent is less than one half of the insured person’s annual income(6)

The annual income of the family member applying to become a dependent is less than 1.3 million yen (1.8 million yen in the case ofsomeone age 60 or older or who is receiving disability pension)

The Western Digital Technologies Health Insurance Association makes a determination taking into account the income of each family(7) member when the person with the higher obligation to support the dependent and the family member applying to become a dependentboth have income*e.g.: If the family member applying to become a dependent is the mother, the Western Digital Technologies Health Insurance
Association verifies and reviews the father's income and the total joint income.
*Individuals who are age 18 or older and under age 65 are at an age that allows them to work, and in many cases they can live
independently without the economic assistance of the insured person.
Accordingly, when applying for a family member who is age 18 or older to become a dependent, the insured person must submit
documentation to certify the individual is unable to work and that they are providing support for most of the family member’s living
expenses.
In cases when a parent or child are of working age in particular, the Western Digital Technologies Health Insurance Associationconsiders age, income, reasons for becoming a dependent and other factors to determine whether to certify the individual as adependent.

● Regarding Records■ This application record does not need to be submitted for dependents who are a child by birth or a child in junior high school or younger.
■ The application record is an important evidential document when certifying dependent qualifications, such as the ability for the insured
person to continually maintain and support the livelihood of the dependent. Please always fill out the entire application record with correct andfactual information.
■ If the application record is incomplete or missing any attached documents, the Western Digital Technologies Health Insurance Association
cannot accept the application because it cannot determine whether to certify the individual as a dependent.
If there are any factual discrepancies after certification, the individual may retroactively lose their certification as a dependent.
■ Please confirm the addendum for the documents to attach.
The Western Digital Technologies Health Insurance Association carefully reviews these materials for certification and may request thesubmission of additional documents depending on the circumstances.

■ The Western Digital Technologies Health Insurance Association uses the information provided herein to fairly certify individuals asdependents by comprehensively understanding the circumstances of support for each individual applying as a dependent.
The personal information collected is not used for any other purpose and is never provided to third parties.
■ The Western Digital Technologies Health Insurance Association reviews the application record and attached documents to then determine
the day of dependent certification.
Pursuant to Article 38 of the Ordinance for Enforcement of the Health Insurance Act, the insured person must submit documents within fivedays when the insured person has or comes to have dependents. Accordingly, the day of dependent certification is generally the date of receipt
if the documents are not received within five days.
However, the Western Digital Technologies Health Insurance Association conducts its review taking into account the Notification ofDependents for Health Insurance (Changes). Therefore, please make sure to fill in the date to add the dependent and all other information.

[Please submit the application record with the Dependent Notification (Change), various evidentiary documents, and the check sheet.]To the Western Digital Technologies Health Insurance Association

Dependent Application Record

Health Insurance

I have read and agree to the terms and conditions of the Dependent Application Records, etc. in the addendum for submission with the Dependent
Application Record.
If information in the application below is provided under false pretenses, I do not object to retroactive loss of qualification for my dependent fromthe day my dependent was certified.
If any corrections are necessary to the items herein, I will cross out the mistake with two lines and affix a revision seal where corrections weremade.
I will return any medical, healthcare business or other healthcare expenses paid up to that point by the Western Digital Technologies Health
Insurance Association as well.
If I obtain employment or if my income fluctuates, I will also promptly contact the Western Digital Technologies Health Insurance Associationand undergo any necessary procedures.
(Y)

(M)

(D)

Name of employer(Seal)

Insurance card code

numberName of insured person(Seal)■ Please answer the following questions about the individual applying as a dependent.
Furigana

GenderRelationship

Date of birthName(Y)

Current address

(M)

(D)

[1] Please provide the circumstances leading to this application for the individual to become a dependent.
Please explain, concretely, the specific reasons for applying for the individual to become a dependent (status of applicant, circumstances leading to financial assistance, anddetails on why the insured person must provide financial support rather than someone else with an obligation to provide support)

Note: The application will be returned if this information is not included.

[2] Please include information about the person applying to become a dependent. (Please circle one applicable item, and ensure that there is no missing
information in each section.)
1. Is the individual currently enrolled in healthinsurance?

No

Name of last insurer (If the individual that is applying is joining the company, please
include their last insurer providing them with health insurance
before joining the new company.

Yes

Voluntary continuation / National health insurance / Health insurance provided by employer/ Mutual benefit association

2. Does the individual apply for a tax exemption
for dependents on their income taxes?

Yes

NoNo

Retirement/Marriage// Childbirth (Due date:
(M)

(Y)

Yes

Employer

Yes(Tentatively from about

Currently applying
Planning to apply(M)(D)coverage lapsed）

Date of resignation:

4. Is the individual currently receiving any
employment insurance (unemployment benefits)
if previously working?

(Y)

Reason [required]（

Reason for resignation

3. Is the individual currently working?

)Company circumstances(D)) / Other ((M))(D)

Monthly income
(Y)

(M)

(D) to(M) Basic(D) daily)
allowance (Tentative date to submit copy of benefit qualification certificate[(Y)(M)(D) ]Currently extending
Reason for extension (Planning to extendyen) Tentative date to submit notification [Benefits ended Date benefits ended:

(Y)

(M)

yen)

(Submit the certificate within two months of the submission date
The dependent application becomes null and void if the certificate is notsubmitted)(Y)

Note: A person receiving 3,612 yen in basic daily
Reason (allowance (5,000 yen for persons age 60 and older) cannot
Not enrolled
become a dependent.

[No / Yes]

Annual income (Salary)

NoYes Annual incomeyen)*“Income” refers to the salary (including bonuses andtransportation expenses). However, pensions and othertemporary income (severance pay, prize money, dividends,insurance refunds, inheritance, etc.) is not designated as theincome described here. In addition, “income” refers togross income and not net income.
“Annual income” differs from that under tax law and is
the estimated income for the next year from the day on
which income is earned.

Pension(D)](D)

Will notreceive

5. Does the individual currently have income?

(M)

NoYes

yen(pension) (yen per year)(pension) (yen per year)

Breakdown*Pension includes surviver, disability, pension, fund, and occupational accident compensation.

Dividends / Interest / Real estate income / part-time income / Other (OtherNo

Yes(yen per month) or (yen per year))6. Does the individual live with the insuredperson?
7. Does the individual receive national or local
government assistance for all or some of the outof-pocket payments for treatment covered byinsurance?

Livingtogether
Livingseparately

Yes

Reason for living separately () Monthly remittance (yen per month)

Please submit copies of any medical certificates or other documents in your possession.

No[3] Please tell us about family other than the relative applying to become a dependent (not required if the person to certify is your spouse).
1. Do any family members live with the person
applying as a dependent?

NoYes

Reason that another family member cannot provide support ()2. Please include information about your other family members to verify whether there is no other person with a higher obligation to support the individual as adependent.* Please also include the relationship from the perspective of the individual applying to become a dependent in the "Relationship” field.
Name

RelationshipAge

Occupation

Annual income

Cohabitation
statusTogether / Separate

Together / Separate

Together / Separate

Address