Health
Insurance

InsuredFamilyMedical Care
Expenses
Application Form

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

12To be filled out by the insured
person (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)□ Showa□ Heisei(Furigana)Name(〒-TEL()

Address
Telephonenumber)(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 accountCreditUnionBank

Name of financial
institution

Agricultural
Cooperative
Other

1. Ordinary 3. Special
4. Deposit at
2. Current
noticeAccount type(Shinkin
BankMainbranchFishery
Cooperative

BranchLocal office
Headoffice)Account number

BranchofficeFill in from the left side.

▼Katakana (Leave one square between your first and last name. Please write diacritic marks (“, °) as one character. )Accountholder
category

Account holder

Beneficiary agent field

Insured person(Applicant)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

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

Medical CareExpenses
Application Form

12

To be filled out by the insured
person (the applicant)Name of theinsured person

Application details

1 Person receiving medicalcare

1. The insured person

2. A dependent family member

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

Date of birth
3 Date of illness
onset or injuryoccurring

2 Name of injury or illness

MMDD,

YYYY

MMDD,

YYYY

4 Cause of injury and progress(in detail)5 Medical institution wheretreatment was received

FromMM

Name

Location

Name of physician etc.
providing treatment

Name

Location

Name of physician etc.
providing treatment

DDToYYMMDD

YY

6 Date(s) treatment wasreceived

Numberof days
day(s)

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

FromMMDDToYYMMDD

YY

Numberof days
day(s)

7 Expenses incurred fortreatment

Yen

8 Details of treatment
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 treatment

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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