The Childbirth and Childcare Lump-Sum Grant additional benefits
for Insured Person or Family Member
Information on insured person[If not using the system of direct payment to medical institutions, or if childbirth took place outside of Japan]
Insurance cardcode and number

CodeNumber●●XXXXXXXX Co., Ltd., XXXX Branch
Telephone number (ext.) 03-1234-5678(999）

ケンポ タロウ

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

Taro Kempo

Address, telephone number, 〒123-4567
etc. of applicant
XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo(daytime phone number)
Telephone number 03-7891-2345

Employee ID number1234567

E-mail address

XXXX＠XXXX.ne.jp

Person who gave birth(circle the applicableperson）

Insured person / Family member (dependent)

Name of person
who gave birth

Hanako Kempo●● (Y) ●● (M) ●● (D)Delivery date

Application details

Name of affiliatedoffice/department

Live birth or stillbirth（circle the applicabletype）
Relationship between theinsured person and born
baby
Name of medicalinstitution
where baby was born

Live birth / Stillbirth / Mixture of live birth and still birth

Date of birthof person who gave birth
Number oflive-bornbabies●● (Y) ●● (M) ●● (D)Number ofstillborn Baby (ies)(ies) babies

1 BabyEldest son

Is the born baby adependent?

XXXX Maternity Clinic

Address of medicalinstitution
where baby was born

In the case of astillbirth,the elapsed period ofpregnancy

YesweeksNo3-3-3 XXXX-cho, Yokohama City, Kanagawa Prefecture■ Complete the following section if applicable

Insured person

1. If the insured person gave birth within six months after retirement→
Insurer’s name, code and number, etc., of the insured person who is currently enrolled

Telephone number

2. Childbirth by dependent within 6 months after qualification→
Name, code and number, etc., of the insured person who was previously enrolled()–Code and number

Information on transfer
destination

Authorization Letter*If you wish to delegate receipt, please complete the authorization letter.
I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

NameRepresentative(individual actually receiving benefits)

Name1234

Bank Number

Date:Bank

Name of financialinstitution●●Central branch●●

Shinkin bank(credit treasury)

Savings account

Other

Type of accountChecking account(567Branch number)

Account number

branch1234567

Name of accountholder(Katakana)

Delivery date(Y)Taro Kempo

Documents forAttachment

Remarks

Municipal head

Physician / Midwife■ Certification section (please receive certification from one of the following)
Name of mother whogave birthSingle birthMultiple birth (babies)

Number of babies bornLive birth or stillbirthLive birth

(M)

(D)

Stillbirth (XXth month or XXth week of pregnancy)

I hereby certify that the above is true and correct
(Y)

(M)

(D)

Address of medical facility
Name of medical facility

Please ask the medical institution
oror midwife
municipal head to certify this section.
Name of physician
Registereddomicile

Name of head ofhousehold

Name of born
baby

Name of mother
Date of birth

(Y)

(M)

(D)

I hereby certify that the above is true and correct
(Y)

(M)

(D)
Name of municipal head

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.
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 (bothsides)
・ When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Date request received(stamp)

1. Copy of agreement document with the medical institution, etc.
2. Copy of receipts issued by the medical institution, etc.
*If childbirth took place outside of Japan, please attach the following documents.
1. Certificate proving the birth 2. Japanese translation of the birth certificate 3. Copy of receipt
4. Copy of documents (passport, etc.) that show the period of overseas travel 5. Consent form for inquiries to overseas medical institutions, etc.

Accenture Health Insurance Society(20230201)