Dependent certification record
I hereby certify that the information listed below is true and correct.
If there are any discrepancies with the facts, I do not object to the cancellation of certification or the refund of the benefits paid by the health insurance society.
Also, if I obtain employment or if my income fluctuates, I will promptly engage in procedures for removing dependents.

To the Executive Head of the Accenture Health Insurance Society
Date: 2021 (Y) 10 (M) 2 (D)Kenpo TaroName of insured person■ Please enter the required information or circle the applicable items for the certified person.
Insurance
Codecard〇〇

NumberReason why application as a(1)dependent was made(2)Please list the healthinsurance in which you are
currently enrolled

〇〇〇〇

Emp.
No.

(5)

(6)

5. Completed receipt of employment insurance benefits]

1. National Health Insurance 2. Health insurance provided by employer
3. Other health insurance/mutual aid association 4. Not enrolled*If you circled 1., 2., or 3. above, please enter the name of your health insurance society[]YesNo(Go to (7))(Go to (4))

YesNo

(Go to (5))(Go to (7))

Yes (Go to (6))[Date of retirement: 2021 (Y) 9 (M) 30 (D)]

4. Completed receipt [Date of completion:

Please list your current
amount of income.

Please list the details of yourincome.

]

3. Currently extending or planning to extend [Reason for extension(Y)

5. Will not receive [Reason:]

(M)

(D)]

]

6. Other [Yes]No(Go to (8))(Go to (10))[Annual income: approx.

(Go to (7))

yen] (Go to (9))
2. Real estate income
4. Self-employed income

A. Old age pension

B. Survivor’s pension

C. Personal pension

E. Corporate pension

F. Onkyu pension

G. Other [D. Disability pension]

6. Social insurance benefits (please circle the type)
A. Injury and illness allowance

B. Maternity allowance

C. Work leave compensation, etc., from industrial accident compensation insurance

D. Other [7. Other [(10)(M) (D)]

2. Currently applying or planning to apply [Date of procedures: 2021 (Y) 10 (M) 1 (D)]

1. Salary (part-time income)3. Interest/dividend income
5. Pensions (please circle the type)(9)

No (Go to (7))[Date of retirement: (Y)[Reason for retirement: To concentrate on childcare ] [Reason for retirement:*If the basic daily amount exceeds
3,612 yen, certification is not possible(5,000 yen for those over 60 yearsold)

(8)

32

Age

3. Quit work and lost all income

6. Other [1. Currently receiving pension

Do you currently haveincome?

Wife

4. Income decreased

Please list the current statusof employment insurance
receipt.

(7)

Relations
hipKenpo Hanako

2. Got married

Have you worked in Japan inthe past two years?
Were you enrolled inemployment insurance?

Name ofcertifiedperson

1. Obtained employment at company(3) Are you currently working?
(4)

〇〇〇〇〇

Do you live with the insuredperson?

]](Go to (10))

No
Reason for living separately [YesAmount transferred in one month []yen]*For details of attached documents, please check the documents list for other documents required for dependent certification.

■ If you want to certify a family member such as parents, parents-in-law, siblings (other than spouse/children living together), please
complete the following section.
No
Yes [Name of spouse:]
Does the certified person(11)
1. Separation due to death 2. Divorce 3. Not yet
have a spouse?
[Annual income of spouse:yen]marriedName■ Please fill in the family(12) structure of the certifiedperson.
Accenture Health Insurance Society

Relationship

AgeHousehold

Annual income

Does the certified person receive any aid?

Cohabit / Separateyen

Yes [yen] / No

Cohabit / Separateyen

Yes [yen] / No

Cohabit / Separateyen

Yes [yen] / No20231101