《 Tentative translation of "SHIKAKU SHUTOKU TODOKE" 》

Only for reference: Do not use this English form.

Application to Enroll in Employees' Health Insurance / Employees' Pension Insurance

Form code

Application to enroll in Employees' Pension Insurance for insured persons aged 70 and older
Date of submission:

Reiwa era/Y/M/DWorkplacenumber-Workplace code

Please enter correct information
carefully; the information you
enter in this form is important todetermine workers' healthinsurance benefits and pension
benefits.

Make sure to enter the workplacecode and workplace number.

Applicant / Employer

I, the employer, hereby confirm each worker's Individual Number (or Basic Pension Number) here is correct.
〒-Address ofworkplaceEnter the workplace information including address.

Name ofworkplace

Labour and Social Security Attorney

Circle applicable type of insured persons in ⑷:1. for male, 2. for female, 3. for miners,
5．for male covered by pension fund,
6. for female covered by pension fund, and7. for miners covered by pension fund.

Name/ address/ contact number

Name ofemployer

Insured person 1Circle applicable category for enrollment in ⑸.
1. Worker to be enrolled in the Employees' Health Insurance and the Employees' Pension
Insurance (excluding Seamen's Insurance)
aid association to public
Phone number 3. Worker seconded from a mutual（） finance corporation
4. Worker as a voluntary and continuous insured person under the Seamen's Insurance⑴⑵(in KANA characters)

InsuredpersonnumberName(Family name)⑸

Enrollment
categoryMonthly
remuneration
amount⑾Insured person 2Address

3. MAA secondee⑹ Individual
Number (orBasic PensionNumber)(in KANA characters)Name(Family name)Enrollment
categoryEHI・EPI

3. MAA secondee
4. Seamen's Ins. volcon⑼
Monthly
remuneration
amount⑹ Individual
Number (orBasic PensionNumber)Name(Family name)

Address

EHI・EPI

3. MAA secondee

Date of birth(First name)⑽

Remarks

Yen

0．No

1．Yes

Circle applicable number in (8) toindicate
whethernotworkplace)
you attach
3. Enrollmentof part-timeworkers or(specific
4. Enrollmentof re-employedworker after retirement
the Reportof Dependents.
5. Other ()1. Residing out of Japan
Reason: 2. Short-term stay
3. Others (5. Showa
era

yearmonth)

day ⑷

Type

7. Heisei era

1．Male2．Female
3．Miner

5．Male（pension fund）
6．Female (pension fund)7．Miner (pension fund)

9. Reiwa era

year

month

day ⑻

Dependents
application

9.Reiwa
era

0．No

1．Yes

Circle the applicable item：
3. Enrollment of part-time workers (specific workplace)
1. Worker aged 70 and older
4. Enrollment of re-employed worker after retirement
2. Enrollment of worker at two workplaces and more
5. Other ()5. Showa
era

yearmonth

1. Residing out of Japan
2. Short-term stay
3. Others ()day ⑷Typeyear(b) (In kind)

Yenmonth

1．Male2．Female
3．Miner

5．Male（pension fund）
6．Female (pension fund)7．Miner (pension fund)day ⑻Dependents
application

9.Reiwa
era

0．No

1．Yes

Circle the applicable item：
3. Enrollment of part-time workers (specific workplace)
1. Worker aged 70 and older
4. Enrollment of re-employed worker after retirement
2. Enrollment of worker at two workplaces and more
5. Other ()Yen

No need to enter address if you give the worker's Individual Number in ⑹ above.
(in KANA characters)〒―(Family name)Reason:⑶Date of birth(First name)

5. Showaerayearmonth

1. Residing out of Japan
2. Short-term stay
3. Others ()

day ⑷

Type

7. Heisei era

1．Male2．Female
3．Miner

5．Male（pension fund）
6．Female (pension fund)7．Miner (pension fund)

9. Reiwa era
1.

EHI・EPI

3. MAA secondee
4. Seamen's Ins. volcon

Address⑶(c) Total (a)+(b)(a) (Cash）

Name⑾Dependents
applicationReason:

Date ofenrollment

InsuredpersonnumberMonthly
remuneration
amountday ⑻Circle the applicable item：
1. Worker aged 70 and older
2. Enrollment of worker at two workplaces and more⑺

(in KANA characters)⑼

5．Male（pension fund）
6．Female (pension fund)7．Miner (pension fund)Yen⑹ Individual
Number (orBasic Pension
Number)⑵

Enrollment
category

1．Male2．Female
3．Miner

9. Reiwa era
1.

⑴

⑸

month

7. Heisei era

4. Seamen's Ins. volcon⑾

Remarks

Yen

InsuredpersonnumberMonthly
remuneration
amountyear
9.Reiwaera

No need to enter address if you give the worker's Individual Number in ⑹ above.
(in KANA characters)〒―(in KANA characters)⑼⑽(c) Total (a)+(b)⑵Enrollment
category⑶

Yen(b) (In kind)

day ⑷

Type

Enter the date of enrollment in (7) and themonthly remuneration amount in (c).

enrollment

⑴

⑸

⑽

Date of birth(First name)
You don't need to enter the address
if you give the worker's Individual
Number in ⑹．
If you enter address, please give full information including prefecture andthe name of the apartment building, together with address in KANA ⑺characters.
Date of(a) (Cash）

monthYen

No need to enter address if you give the worker's Individual Number in ⑹ above.
(in KANA characters)〒―

1.

Date ofenrollment

Remarks

Yenyear

9. Reiwa era⑺

Yen(b) (In kind)

5. Showaera
7. Heisei era(c) Total (a)+(b)(a) (Cash）

Insuredpersonnumber⑸Date of birthEnter the worker's 12-digits Individual Number in (6), only after theemployer confirmed the workers' identification.
Or you may enter the worker's 10-digits Basic Pension Number
which is printed in his/her Pension Handbook: please align it tothe left in the (6) column.

⑵

Address

Insured person 3

EHI・EPI⑶(First name)⑴⑾

Insured person 4

1.

4. Seamen's Ins. volcon⑼

Receipt date stamp(a) (Cash）(b) (In kind)⑹ Individual
Number (orBasic Pension
Number)year⑺

Date ofenrollment⑽(c) Total (a)+(b)Remarks

Yen
Yen

month

day ⑻

Dependents
application

9.Reiwaera

0．No

1．Yes

Circle the applicable item：
3. Enrollment of part-time workers (specific workplace)
1. Worker aged 70 and older
4. Enrollment of re-employed worker after retirement
2. Enrollment of worker at two workplaces and more
5. Other ()Yen

No need to enter address if you give the worker's Individual Number in ⑹ above.
(in KANA characters)〒―

Reason:1. Residing out of Japan
2. Short-term stay
3. Others (To workplaces covered by the Employees' Health Insurance managed by the EHI Association (KYOKAI KENPO)
If you are filing this form only to enroll the worker(s) aged 70 and older in the Employees Pension Insurance, please circle 1. and 5. in column ⑽ , and enter "該当届のみ"in Japanese in ( ) parenthesis in 5. ( Please note that we don't reissue the Employees' Health Insurance certificate (ca rd) in this case.))