Information on insured person

Application for Health Insurance Payment of Medical Care Costs for Insured Person or Dependent[for overseas medical expenses]
Insurance cardcode and number

CodeNumber●●XXXX
ケンポ タロウ

FuriganaName●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo〒123-4567
Address, telephone
number, etc. of applicant
XXXX Condominium, #456
(daytime phone number)
Employee ID
number
Person undergoing medicaltreatment(circle the applicable person）

1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

1234567

XXXX＠XXXX.ne.jp

E-mail address

Name of person
Insured person / Family member (dependent) undergoing medicaltreatment

Name of injury /illness
Cause and progressof symptoms

Application details

Name of affiliated
XXXX Co., Ltd., XXXX Branch
office/department Telephone number (ext.) 03-1234-5678(999）

Taro Kempo

Date of birth ofperson undergoing
medical treatment

Influenza●● (Y) ●● (M) ●● (D)I had a high fever and underwent an emergency examination at a hospital while
traveling.

Name of medicalinstitution where
examination wasconducted

Period during which
medical treatment
was conducted

XXXX Clinic
From ● (Y) ● (M) ● (D)to ● (Y) ● (M) ● (D)USD $200

Cost of treatment

Period of overseas
travel●Address of medicalinstitution
where examination wasconducted
If hospitalized during theperiod listed on the left,days
the period of that
hospitalization

From ● (Y) ● (M) ● (D)to ● (Y) ● (M) ● (D)Was the need for medicalcare caused by a third
party (traffic accident,etc.)?

● daysWashington D.C., U.S.A
From(Y)

(M)

(D)

to(Y)

(M)

(D)

days

Content oftreatment

Underwent medical treatment andreceived administration of drugs

Purpose ofoverseas travel

Touring overseas

If the need for medicalcare was caused by athird party, please
describe the situation

No / Yes*If you wish to delegate receipt, please complete the authorization letter.

Information ontransfer destination

Authorization
Letter☑(1) I hereby entrust the receipt of benefits based on this claim to the employer. ← Insert a check (☑) in the box of the applicable item.
□(2) I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)Name

Date: ● (Y) ●● (M) ●● (D)Taro Kempo

Central branch
Bank
Name of financial
Branch number
Shinkinbank
Please fill in the section for the authorization letter, except for persons enrolled
institution
Branchin(credit treasury)

Name ofaccount holder
Checkingaccount(Katakana)If you area personenrolled in voluntary and continuous health insurance
coverage or aSavings
account
voluntaryand continuous
health insuranceOther
Account coverage and retirees.

Type of account()number[Documents for Attachment]

retiree, please fill in the section for information on transfer destination.

1. Attending Physician's Statement

2. Itemized Receipt

3. Receipt of payment made overseas (original copy)

5. Copy of document showing the period of overseas stay (copies from passport, etc.)

4． Japanese translation of attached documents

6. Consent form for inquiries to overseas medical institutions, etc.

Remarks

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.

Date request received(stamp)One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number
card (both sides)
・ When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Works Human Intelligence Health Insurance Society(20210401)