Applicant information

Claim for Health Insurance Payment of Funeral Expenses (Costs)additional
benefits
When the insured
person diesfor Insured Person or Family Member (When a family member applies)
Insurance cardcode and number

CodeNumber●●XXXX

Hanako Kempo

Employee ID
number● (Y) ● (M) ● (D)●● (Y) ●● (M) ●● (D)1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

No need to fill in

Date of deathNo need to fill in

Applicant date ofbirth

Name of applicant〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456
(daytime phone number)

Name of affiliatedoffice/department

XXXX＠XXXX.ne.jp

E-mail address

Was it caused by theactions of a third party?

Acute heart failure

Cause of deathYes / No■ For application submitted upon the death of a family member (a dependent)

Please enter the applicant's informationsuch asRelationshipaddress, phone number,and emailaddress.
the insured
Date of birth(Y)(M)(D) withName of family
memberperson

Application details

If you fall under one of the following categories, please enter the name of his/her past insurer, and the health insurance code and number.

Name ofinsurer(1) Died within 3 months after being qualified as a dependent by this health insurance society(2) Died while continuing to receive the injury/illness allowance or maternity allowance after being disqualified from this health insurance
society to which he/she was previously enrolled(3) Died within 3 months after the end of receiving (2) after being disqualified from the health insurance to which he/she was previouslyenrolled

Phone number()Code andnumber■ For application submitted upon the death of the insured person
Name of insured
personTaro Kempo

Personal relationship between
the insured person andapplicant

Date offuneral

Wife

Burialexpensesyen

If you fall under one of the following categories, please enter name of the insurer and the code and number of the health insurance in which
the deceased had been enrolled after retirement.

Name ofinsurer(1) Died within 3 months after being disqualified from this health insurance due to retirement, etc.

Phone number()If the applicant is a spouse, child, or other person whose livelihood wasCode andbyof theinsured
person,(3) Died withinsupported
3 months after the end
receiving(2) after being
disqualified there is no need to fill out the form.number
Column to be certified by
the business owner(2) Died while continuing to receive the injury/illness allowance or maternity allowance from this health insurance society after being
disqualified

Name ofthe deceased

Insured person or dependent

Please ask your employer
for/ Dependenta certificate Hfor
Insured person/ R this(Y) section.
(M)(D)
Ifyoucannot
receiveacertificate,pleaseattachdocuments
I hereby certify that the above is true and correct.
Reiwa
(Y)
(M)
(D)
which prove that death occurred (death certificate, burial
Office address
Name of officepermit, etc.).

Information on transfer
destination

Authorization Letter

Name of employer*If you wish to delegate receipt, please complete the authorization letter.

Telephone number

I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)

NameType of account●●
Other(567Central branch●●

Shinkin bank(credit treasury)

Savings account)●●,●●,●●

Branch number
Bank

Name of financial
institution

Date:(Hanako Kempo

1234

Bank Number

Checking accountRemarks

Date of death)

Account
number1234567

Name ofaccount holder(Katakana)branchTaro Kempo

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.
One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number card (both sides)
・When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Section to be completed by the labor and social security attorney submitting the application on behalf of the insured

Accenture Health Insurance Society

Date request received (stamp)(20220401)

Applicant information

Claim for Health Insurance Payment of Funeral Expenses (Costs)additional benefits
for Insured Person or Family Member
When a family member dies
Insurance cardcode and numberCodeNumber●●XXXX

Name of affiliated
XXXX Co., Ltd., XXXX Branch
office/department Telephone number (ext.) 03-1234-5678(999）
Applicant date ofbirth

Name of applicant

Taro Kempo〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456
(daytime phone number)
Employee ID
number1234567

Date of death● (Y) ● (M) ● (D)●● (Y) ●● (M) ●● (D)1-2-3 XXXX-cho, XXXX Ward, Tokyo
Telephone number 03-7891-2345

XXXX＠XXXX.ne.jp

E-mail address

Was it caused by theactions of a third party?

Acute heart failure

Cause of deathYes / No■ For application submitted upon the death of a family member (a dependent)
Relationship

Name of familymember

Hanako Kempo● (Y) ● (M) ● (D) with the insured

Date of birthApplication details

If you fall under one of the following categories, please enter the name of his/her past insurer, and the health insurance code and number.

Name ofinsurer(1) Died within 3 months after being qualified as a dependent by this health insurance society(2) Died while continuing to receive the injury/illness allowance or maternity allowance after being disqualified from this health insurance
society to which he/she was previously enrolled(3) Died within 3 months after the end of receiving (2) after being disqualified from the health insurance to which he/she was previously
enrolled

Name of insured
personPersonal relationship between theinsured person and applicant

Date offuneralBurialexpensesName ofinsurer

Name ofthe deceased

Phone number()Code andnumber(3) Died within 3 months after the end of receiving (2) after being disqualified

Column to be certified by
the business owner)

yen(2) Died while continuing to receive the injury/illness allowance or maternity allowance from this health insurance society after being
disqualified

Insured person or dependent

Date of death

Please ask your employer
fora certificate Hfor
Insured person/ Dependent/ R this(Y) section.
(M)
(D)
Ifyou
cannotreceiveacertificate,pleaseattach
documents
I hereby certify that the above is true and correct.
Reiwa(Y)(M)(D)
Office address
which prove that death occurred (death certificate, burial
Name of officepermit, etc.).

Name of employer*If you wish to delegate receipt, please complete the authorization letter.
Authorization Letter(■ For application submitted upon the death of the insured person(1) Died within 3 months after being disqualified from this health insurance due to retirement, etc.

Information on transfer
destination

Phone number

Code andnumber

If you fall under one of the following categories, please enter name of the insurer and the code and number of the health insurance in which
the deceased had been enrolled after retirement.

Telephone number

I hereby entrust the receipt of benefits based on this claim to the representative listed below.
Insured person(applicant)

Name

Representative(individual actually receiving benefits)

Name1234

Bank Number

Type of account●●
Other()

Accountnumber)

Date:567
Central branch●●

Shinkin bank(credit treasury)

Savings account(Branch numberBank

Name of financial
institution

Checking accountRemarks

Wifeperson

1234567

Name ofaccount holder(Katakana)branchTaro Kempo

Individual number (not required when entering the code and number from the insured person's card)*If you entered your individual number, please attach the following documents to confirm your individual number and identity.
One of the following: (1) Copy of individual number notification card, (2) Copy of certificate of residence listing individual number, (3) Copy of individual number card (both sides)
・When attaching (1) or (2) above, also attach one of the following: copy of driver’s license or copy of passport

Section to be completed by the labor and social security attorney submitting the application on behalf of the insured

Accenture Health Insurance Society

Date request received (stamp)(20220401)