Person in charge

Managing director Clerical supervisor

Reissue due toLoss or Damage

Insurance Card
Elderly Recipient Certificate

Application Form

I attest that the application below is true and correct.
I will pay 3,000 Yen as the cost for reissuing an insurance card.
Name of insured person[InsuranceCodecard code andNumber
numberName ofinsured
person

Emp.
No.

〇〇〇〇〇
ｹﾝﾎﾟ

Furigana〇〇〇〇〇

Date ofbirth]

(Y)

1980
Postalcode

ﾀﾛｳ

Kempo Taro(M)

(D)

101

Certificationacquisition date(Y)

(M)

2020

(D)

41151-0051

X-X-X Sendagaya, Shibuya-ku, Tokyo
Address of theinsured person

xxxxx Co., Ltd.
XXXX Department XXXX Section

Reason for submission(Please circle the applicablereason)

Would you like to have thecard reissued?

1. Loss

Telephone number ０３(XXXX)XXXX(loss / theft / missing) Damage (including print that has rubbed off)

3. Other (1. Yes)

2. No(Please circle the applicable answer)

２． For dependent

Furigana(1)

ｹﾝﾎﾟ ﾊﾅｺ

Kempo Hanako

Furigana
Complete this section if
the applicable person is (2)a dependent
Furigana(3)
Place where the cardwas lost
Have you notified thepolice?

1. HomeYes / No

Relationship

1. For insured person

(Y)

Wife

Date of birth

RelationshipApplicable person(Please circle the applicable item)

Date of birth

Relationship

Section to be filled out by the insured person

Name of affiliatedcompany
Name of affiliateddepartment

100

Kempo Taro

Date of birth

1995(M)

0(D)

92

1(Y)

(M)

(D)

(Y)

(M)

(D)

2. Other than home ( somewhere between JR Kinshichō Station and home ) → Police must be notified
Notification
destination

PoliceDate ofKinshichō Station notification

Date:No.

1234*Please describe in as much detail as possible

Circumstances under
At around 10:30 pm on XX (Y) XX (M) XX (D), I used a wallet containing my insurance card when exiting the ticket gate at the station closest towhich the card was lost
my home (JR Kinshichō Station). Afterwards, when I went shopping at a convenience store near my house at around 11:00 pm, I noticed that myor damaged
wallet was lost. I also lost the insurance card that was inside.
◎ If you are applying for reissuance due to damage to your health insurance card, please attach the damaged health insurance card to this application form.

Notification of Loss of Insurance Card / Elderly Recipient Certificate (complete this section only in the case of loss)
As stated above in the application, I lost my insurance card/elderly recipient certificate. I will be more careful when handling the card in the future.
If I find my insurance card/elderly recipient certificate, I will return it immediately.
I assume full responsibility for any accidents that may occur in my insurance benefits due to my loss of the insurance card, etc.

Date: 2021 (Y) 12 (M) 1 (D)Name of insured person

Kempo Taro
Date of submission:

To the Executive Head of the Accenture Health Insurance Society

If your insurance card was lost or stolen, please immediately notify the health insurance society and police.
Also, we recommend using the Personal Declaration System* that is established by the personal credit information agency.
If the insurance card is fraudulently used by a third party, the health insurance society shall not assume any responsibility.
*Personal declaration system: A system in which information such as the loss or theft of a stolen ID card is registered with a personal credit
information agency. This enables the member companies of the credit agency to perform a more careful credit screening.
*For details on the procedures, etc., please directly contact the personal credit information agency.

Date request received (stamp)

20210401