Person in charge

Managing director Clerical supervisor

Health Insurance Notification of Change of Covered Dependents (Addition)
Section to be completed by the labor and social security attorney / health insurance society(Y)Section for dependent

Section for dependent

Section for insured
personAcquisition
date:

Insurance
card

100
Emp. No.
Number 〇〇〇〇
Code

ケンポ

(Furigana)Name(First name)

Taro

ケンポ

ハナコ

Date ofbirth

Hanakoindividual
number(Last name)

Name

RelationshipWife

Occupation

Unemployed

Income(annualincome)

(Y)

(M)

ケンポ

(Last name)

Relationship(D)2021 02 01(Furigana)Name

0,000 yen(in tens of thousandsof yen)

IncomeSecond Occupation University (annualoldest son
student income)

(Y)

(M)

Date ofbirth

Jiro

individualnumber(D)2021 02 01

Reason1. Cohabitation
2. Living separately

Section for dependent

1-2-3 XXXX, XXXX Ward, Tokyo–〇〇(Y)△△△△(M)

–

□□□□

(D)

1990 12 22

Gender 1. Male

2. Female

Remarks(Y)

Name(D)

Gender 1. Male

2. Female

20500
1600 Pennsylvania Avenue, NW Washington, DC
In the case of living separately

Postal code

(1)Remarks(Y)

Date ofbirth(First name)(M)*2017 06 01

Foreign study(Furigana)(Last name)

Remarks

123-4567

Retirement

ReasonAddress(D)

2. Living separately

ジロウ

0,000 yen(in tens of thousandsof yen),000 yen(In thousands of yen)

1. Cohabitation In the case of living separately Postal code

(First name)

Kempo

Date ofbecoming adependent

Address(M)

1990 10 11

Telephone number(First name)

Kempo

Date ofbecoming adependent

Address

Kempo(Furigana)(Y)

Postalcode

タロウ(Last name)(D) Standard
ｍonthly
remunerationDate ofbirth○○○○〇(M)(M)*(D)
Gender 1. Male

2. Femaleindividualnumber
Income(annualincome)Occupation

Relationship(Y)

Date ofbecoming adependent

0,000 yen(in tens of thousandsof yen)
(M)

(D)

Address

1. Cohabitation In the case of living separately Postal code
2. Living separately

ReasonRemarks**If there is no certificate of residence for the dependent in Japan, please check the requirements on the back and enter the applicable number in the remarks column.

Date request received (stamp)

Officeaddress

Postal codeHuman resources
reception date

Name ofoffice

(M)

(D)

Labor and social security attorney submitting the application on behalf of the insured

Name ofemployer
Telephonenumber(Y)（）

Accenture Health Insurance Society 20210401

*If there is no certificate of residence for the dependent in Japan, please check if any of the following requirements
apply to the dependent and enter the applicable number in the remarks column.
Number(1)(2)

Requirement

Students studying overseas

Person accompanying an insured person who is stationed forwork in a foreign country[Specific example]
Person for whom a dependent visa is issued

Documents for Attachment

Copy of visa, student ID, enrollment certificate, admission
certificate, etc.

Copy of visa, letter of appointment for overseas assignment,
residence certificate issued by an overseas public institution, etc.

Person who temporarily travels abroad for sightseeing,
recreation, volunteer activities, or other purposes other thanemployment

(3)

(4)

(5)

[Specific examples]
In principle, a person whose visa has an expiration date; forexample, person who travels using the working holiday
system, family member who accompanies students studying
abroad, etc.
Person who has a personal relationship with the insured
person while the insured person is assigned to a foreigncountry and is recognized as equivalent to (2).

Copy of the visa, proof of the volunteer dispatching agency,
volunteer participation agreement, etc.

[Specific examples]
Copy of documents certifying birth, marriage, etc.
・ Child of insured person born during overseas assignment
・ Spouse who was married locally during an overseas
assignment
・ Specially-adopted child who was adopted during overseas
assignment
In addition to the persons listed in (1) to (4), persons who arerecognized as having their lifestyle based in Japan inconsideration of the purpose of travel and othercircumstances
Copy of documents certifying birth, marriage, etc.
[Specific example]
Children born while a dependent is living overseas for reasons
such as foreign study

Accenture Health Insurance Society