《 Tentative translation of "SHINKI TEKIYO TODOKE" 》 Only for reference: Do not use this English form.

Form code
2101

Date of submission

Employees' Health Insurance / Employees' Pension Insurance

Enter date of submission on top of the form.

Application for Workplace Coverage/Y/M

Receipt date stamp/D〒 Postal code
Workplace(in KATAKANA characters)

Employeraddress(in KATAKANA characters)

Name ofworkplace

Labor and Social Security Attorney
Name, address and phone

Telephone（number(1)Name of）(2)(in KATAKANA characters)

employer (or(Last name)(First name)

Address of〒 Postal code

Name
Contactrepresentative)(3)

Enter name of Labor and Social Security Attorney "shakaihoken romushi", if applicable, who issubmitting this application for you.

Extension numberperson-Item (2): Make sure to enter contact person's detail to allow us to ask about your application ifneeded.

employer (orrepresentative)
(4)

Name

Agentof theemployer

(6)

(5)

(in KATAKANA characters)(Last name)(First name)〒 Postal code-Address(7)Type of businessBusiness category（Type ofbusiness）(8)

CorporationWorkplace information

category(10)

Head office orbranch(13)Enter name, address and phone number of the company (workplace) in the top box “Employer”.
If possible, enter appropriate abbreviation in Japanese KATAKANA characters in front of the nameto indicate workplace type as below:"カ" for Kabushiki gaisha"ユ" for Yugen gaisha"メ" for Gomei gaisha"シ" for Goshi gaisha
If other, enter as is.
In this form, providing KATAKANA characters is optional (not mandatory.)

Name of Healthyear

Date ofcoverage（do not fill in）

1. Corporation(9)

2. Individualinstitution
1. Head officenumber(11)Domesticor foreign

2. Branchcorporatio(in KATAKANA characters)

2. Corporate registration
numberName of

1. Domestic corporation (12)Code of Labor & Social Security Attorney

LSS

2. Foreign corporation

Attorney(14)

Health Insurance Society(15)

Item (12): Enter name of Labor and Social Security Attorney "shakaihoken romushi", if applicable, towhom you entrust submission of other reports or applications.

1. Corporate number

Corporate

3. National or local public

Insurance Society

Item (14): Enter Employees' Pension Fund number and name if applicable.

EP Fundnumber andEmployees' Pension Fundname(16)Salary calculation
date(18)

Pay day(17)Month of pay
th day of a monthth day of current month

Remuneration

raise(19)report form

monthmonth

monthmonthth day of next month

Bonus

Bonus reportmonthmonth(22)1. Monthly salary

5. Hourly wages

2. Daily wages

6. Annual salary

3. Daily basis salary

7. Other

4. Percentage pay（）

Applicableallowancesmonth

5. Regular attendance

2. Housing

6. Overtime(23)

Payment inkind

3. Supervisory po 7. Other
4. Commutation

1. Unnecessary
2. Necessary (by digital medium (CD) )Item (13)： Enter name of the Health Insurance Society if applicable.

1. Unnecessary
2. Necessary (by digital medium (CD))

month

1. Family

0. Necessary (by paper)

0. Necessary (by paper)

(20)

month

(21)

Payment system

Item (9): If the employer category is a corporation or a national or local public institution, circle "1.
Corporate number" and enter 13-digit corporate number.

daymonth

1. Meal

5. Other

2. Housing（)

3. Clothing

Item (16): Enter month of a year of pay raise.

4. Train/bus pass）(24)

2． Number of workers subject to social Insurance coverage

1. Total number of workers including executive members

3. Number of workers not subject to socialEmployee

insurance coverage by worker types:

information
Note: Enter average work days/hours for ⓑ, ⓒ, and ⓓⓐ Executive members

Remuneration (payable/no),ⓑ Short-time contract

About

work days / monthAboutwork hours / week

ⓒ part-timeAboutwork days / monthAboutwork hours / week

ⓓ "ARUBAITO" side-job
(25)

About

Full-time workers,work days / month

Regular workdays/hours ofworkplace

(26)

Notes

days / month

hours andminutes / week

hours andminutes / day

About

Part-time workers

work hours / week

Item (19): Enter bonus month of a year.

Item (24)： Enter total number of workers and number of workers who are subject to social
insurance coverage. Enter number of workers not subject to social insurance coverage inappropriate columns in the table and enter their work hours.