Attending Physicians Statement

To: Tokio Marine & Nichido Life Insurance Co., Ltd

1.Name of patient

Sex□M

Date of birth (dd/mm/yyyy)□F/

2. Diagnosis

10.In case of acute myocardial
infarction(ii)Illness/injury
for admission/operation(ii)(i)Inception
date(i)//(dd/mm/yyyy)□doctor's presumption□patient's claim

11. In case ofstroke

3.First medical consultation//(dd/mm/yyyy)

4.Period of treatment

From//(dd/mm/yyyy)

ToTo （dd/mm/yyyy）//Whether limitation of work (excluding the one such as housework / desk work) has
continued more than 60 days from the first visit.
□Yes
□No

Whether limitation of work (excluding the one such as house work / desk work ) has continued more than60 days from the first visit.
□Yes
□No

(iv)Complications/Additional
diagnoses(iv)(iii)Causeof (ii)(iii)

From （dd/mm/yyyy）//9.Period of occupational disability/

Whether sequelae of central nervous system has continued more than 60 days from the first visit.
□Yes□No
If Yes, please describe details://(dd/mm/yyyy)

5.Period of hospitalization
From//(dd/mm/yyyy)

To (*1)

From//(dd/mm/yyyy)

To (*2)//(dd/mm/yyyy)//(dd/mm/yyyy)

12. In case of neoplasm

At the date of (*1) , patient:□still in hospital□transfered to other hospital□discharged□other()At the date of (*2) , patient:□still in hospital□transfered to other hospital□discharged□other()(i)Finaldiagnosis(i)//(dd/mm/yyyy)(ii)Examination
for Diagnosis(ii)
Examination

Date of final result

ResultHistology//(dd/mm/yyyy)

Cytology//(dd/mm/yyyy)

Other examination//(dd/mm/yyyy)

6.Previous medical facility/physician (if any)
Name of the medical facility

Name of the physician

Address

Date of first visit//（dd/mm/yyyy）

TNM classification, Invasion depth, Condition

7. Operation(*Operation includes chest tube drainage, intraperitoneal drainage, stent change and port implantation.)
Type of operation:
operation Select from the list below and write numbers (1-12) in the item of "Type of operation"
1 craniotomy
2 burr hole opening
3 thoracotomy
4 thoracoscopy

5 laparotomy
6 laparoscopy
7 transurethral
8 transvaginal

9 endoscopic surgery or transluminal intervention
10 laser surgery
11 shock wave lithotripsy
12 others

Type of operation Name of operation(1-12)
Side□ Left
1 □Right□Not applicable

Date （dd/mm/yyyy）

Bone/joint surgery□open□closed□Not applicable

In case of skin graft/skin flap, surgical area is□equal to/more than 25cm2□less than 25cm2

Type of operation Name of operation(1-12)

Date （dd/mm/yyyy）

Bone/joint surgery□open□closed□Not applicable

Manipulation of Muscle/tendon/ligament (ex.dissection, ligation )□Yes□No□Not applicable

In case of finger (hand/foot) surgery , surgical area□includes metacarpophalangeal joint□does not include metacarpophalangeal joint

In case of skin graft/skin flap, surgical area is□equal to/more than 25cm2□less than 25cm2

8.Radiation therapy and thermotherapy□Thermotherapy□Brachytherapy□Others

At the date of(*3)

Period (dd/mm/yyyy)
From//To//□under radiation therapy□radiation completed))

In case of colon cancer,□m□sm or deeper

Present condition□cured□therapy continued

Name of Antineoplastic
Date of administration (mm/yyyy)/， /， /，

Gy/，/，/，/，/

13.Outpatient
13.Outpatient visit dates for treatment
Month/Year

Please circle the dates.

/

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/

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/

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/

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/

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/

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/

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

I hereby certify that the above-stated facts are true and correct.
Date of Certification

Address of hospital/clinic:

doze□remission(iii)Has
this patient ever diagnosed malignant or non-invasive carcinoma (including carcinoma in situ)
(iii)
□No
□YesDiagnosis:
Date of Diagnosis//(dd/ mm/ yyyy)

Country:place

For correction, please add your signature next to the correction site.
All copies require your signatures.
If you need more space for description, please use the back of the paper and add your signature next to the writing.

CB136) M((iv)Antineoplastic(iv)□not administered□will be administered□being administered

Manipulation of Muscle/tendon/ligament (ex.dissection, ligation )□Yes□No□Not applicable

In case of finger (hand/foot) surgery , surgical area□includes metacarpophalangeal joint□does not include metacarpophalangeal jointSide□ Left
2 □Right□Not applicable

T() N(Stage(/Name of hospital/clinic:
Department:
Name of Doctor/(dd/mm/yyyy)
Telephone number:
Signature