Person in charge

Managing director Clerical supervisor

Becoming insured under an alternate policy (when thepolicyholder starts working and becomes eligible foralternate health insurance coverage)

Written Notice for Loss of Qualification as a Voluntarily and Continuously Insured Person
To the Executive Head of the Accenture Health Insurance Society
I hereby submit this notice and make this application to lose the qualification as a voluntarily and continuouslyinsured person as described below.
Date:
Insurance card code andnumber

〇〇

Code

○○○○○

Numberケンポ

Furigana
Nameタロウ

Kempo TaroPostal code151-0051

X-X-X Sendagaya, Shibuya-ku, Tokyo

Address○○Phone number
Date of birth

Reason for loss ofqualification

(Y)

(M)

(D)

(○○○○ )(〇〇 )1. Obtained employment (obtaining employment effective
2. Other（

1. Enclosed

Insurance card

yearsof age

Gender

2021

(Y)

○○○○
Male / Female

4 (M) 1 (D)）

Total

3sheets

Insurance card
Reason()2. Not enclosed
Scheduled return dateIssuance of a certificate oflosing qualification

1. Want issuance

(Y)

(M)

(D)

2. Do not want issuance(Note 1) If you enroll in other health insurance due to obtaining employment, please attach a copy of your newly
acquired health insurance card.

*Column to be filled out by the healthinsurance society(Note 2) If you lost your insurance card, please attach the notification of insurance card loss.

Date of losing
qualification

(Y)

(M)

(D)

*Column to be filled out
by the health insurance
societyAmount of insurance
premium to berefunded

Date request received (stamp)yen(Y)(M)(D) to(Y)

(M)

(D)

Remarks20210401

Person in charge

Managing director Clerical supervisor

When the applicant has notified the insurer that youwish to lose his/her eligibility using the prescribed
application form.

Written Notice for Loss of Qualification as a Voluntarily and Continuously Insured Person
To the Executive Head of the Accenture Health Insurance Society
I hereby submit this notice and make this application to lose the qualification as a voluntarily and continuously
insured person as described below.
Date:
Insurance card code andnumber

〇〇

Code

○○○○○

Numberケンポ

Furigana
Nameタロウ

Kempo Taro
Postal code151-0051

X-X-X Sendagaya, Shibuya-ku, Tokyo

Address○○Phone number
Date of birth

Reason for loss ofqualification

(Y)

(M)

(D)

(○○○○ )(〇〇 )yearsof age

1. Obtained employment (obtaining employment effective
2. Other（

1. Enclosed

Insurance card

Gender(Y)○○○○
Male / Female

(M)

(D)

Wish to lose eligibility at 2022/2/1.

Total）

sheetsInsurance card
Reason(For a hospital visit)

2. Not enclosed
Scheduled return dateIssuance of a certificate oflosing qualification

1. Want issuance2022(Y)

2 (M) 1 (D)

2. Do not want issuance(Note 1) If you enroll in other health insurance due to obtaining employment, please attach a copy of your newly
acquired health insurance card.

*Column to be filled out by the healthinsurance society(Note 2) If you lost your insurance card, please attach the notification of insurance card loss.

Date of losing
qualification

(Y)

(M)

(D)

*Column to be filled outby the health insurance
societyAmount of insurance
premium to berefunded

Date request received (stamp)yen(Y)(M)(D) to

(Y)

(M)

(D)

Remarks

20210401