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Insured Lump-sum Payment for
HealthInsurance Family Childbirth/Childcare
Information on Insured (Applicant)SymbolEntered by insured (applicant)Date of birth

NumberInsurance Card(Aligned to theright)

2YY

Designated Bank Transfer A/CMMDD

HeadOffice

Branch□ Showa□ Heisei

Name(Postal codeAddress)－To DoFu KenPhone No.

(Daytime contact)

TEL()□ I delegate the submission of this Request to Employer. (In case of delegation, put a check in the box.)
Shinkin
CreditBank
Union
AgriculturalFishery
CoopCoopBank

Name offinancialinstitutionOthers

1. Ordinary 3. Separate

Deposit type

2. Current

4. Call(Local office)

HQ.

A/C No.

Sub-office

Please enter aligned to the left.

▼ In katakana (Please leave one space between the first and last names, and enter symbols “゛” and “゜” as onecharacter.)

A/C
category

Account name

Receiving Agent Section

Insured(Applicant)I hereby authorize the following agent to receive benefits based on
this Request.

2. Agent

Reiwa YY MM DD

Name

Address: Same as the address in “Information on
insured (applicant)”(Postal code

AgentAgent1. Applicant－) TEL()

Address(Account holder)(Account holder)

Relationshipbetweenmandator andagent

NameA form “Entered by insured (applicant)/doctor/ municipality mayor ” continues on page 2. ->>>
(R2.12)Name of submitting
Labor and Social
Security Attorney

Stamp of receipt date

The personal information you provide is gathered to help the Bosch Health Insurance Society undertake its operations fairly and inaccordance with the Health Insurance Act and relevant notifications. Under no circumstances will this personal information be provided toa third party or used for any purpose other than those stated above. In certain cases, we may contact you to seek clarification of details
you have provided, or, if necessary, ask you to provide additional supporting documentation. Please address all inquiries concerning thehandling of personal information, requests for disclosure of personal information, and so forth to the General Affairs Section of the Bosch
Health Insurance Society (telephone: 0493-22-0890).
*To find out more about how we handle personal information, please refer to the “Privacy Policy” on our website.

Bosch Health Insurance Society

1/212Insured Lump-sum Payment for
HealthEntered by applicant/doctor/mayor of
Insurance Family Childbirth/Childcare
municipality
Name of insured
Application Detail

1. Person who gavebirth

1. Insured

1-(i)In case of family member

2. Family member (dependent)
Date ofbirthName

2. Date of delivery

Reiwa

3. Live birth or stillbirth
3-(i)Number of newborn for“Live birth”

4. Medical institution,etc. delivered

1. Live birth

pers.

MMYY

2. Stillbirth

MMYYDDDD

3. Live birth / Stillbirth mixed

3-(ii)
Number of stillborn for“Stillbirth”

Namepers.

3-(ii)-(1)Elapsed time of pregnancy inFullcase of "stillbirth”

weeks

Location

5. Person who gave birth

1. Yes Insured  Did you give birth within 6 months from the date of resignation?
 Family member  Has the baby been born within 6 months after joining our society?

Symbol/Number5-(i)-(1)1. Received / To be received

For the above childbirth, Lump-sum Payment forChildbirth/Childcare from Insurer in 5-(i) is:

Certified bydoctor/midwife

Certified bymunicipality mayor(production only)

Certification Section (Fill in one of the boxes)

Name ofperson givingbirth□ Single birth □ Multiple birth  (2. No

Name ofInsurer

5-(i)If “Yes,” enter the “Name of Insurer” and “Symbol/Number”.
 Insured  Insurer currently subscribed to Family member  Insurer subscribed prior to joining our society

Number ofnewborn□ Showa□ Heisei□ Reiwa

Date of delivery

Reiwa

Live birthor stillbirth□ Live birthchldn.)

I hereby certify that there is noLocation of medical institution

discrepancy as described above.

Name of medical institution

Reiwa YY MM DD

Name of doctor/midwife

YY□ Stillbirth  (2. Not receivedMMDD

weeks pregnant)Name ofheadhouseholder

Registereddomicile
Name ofmother

Name ofnewborn

I hereby certify that there is nodiscrepancy as described above.
Reiwa YY MM DD

Name of municipality mayor

Date ofbirth

Reiwa

YYMMDD□ This notification meets the requirement (i) or (ii). (Please put a check in the box.)(i) This Request is prepared by the applicant (insured).
(ii) The applicant confirmed that the contents are correct.

Bosch Health Insurance Society

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