Person in charge

Managing director Clerical supervisor

Health Insurance Notification of Change of Covered Dependents (Addition)(Name Change Report)
Section to be completed by the labor and social security attorney / health insurance society(Y)Section for insured
personAcquisition
date:

Insurance
card

CodeNumber(Furigana)

ケンポ

Kempo
ケンポ ホケンEldestson

Date ofbecoming adependent

Occupation

Unemployed

Income(annualincome)(Y)

Date ofbirth

Taro

Individualnumber(D)

20200122(Last name)NameIncome(annualincome)Occupation

Relationship(Y)

Date ofbecoming adependent

Address

Section for dependent

(Y)

(M)

1975 101,000 yen(In thousands of yen)(D)
Remarks

1-2-3 〇〇, 〇〇-ku, Tokyo–〇〇
(Y)

△△△△
(M)

–□□□□

(D)

20200122

Gender 1. Male

2. Female

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

ReasonRemarks

If you want to change or correct the(M)(D)
name ofDate
yourof dependent(Y)(family(First name)birthplease fill out the "Healthmember),IndividualInsurance
Notification of Change ofnumber
Coveredwith theIn the Dependents"case of living separately Postal code
0,000 yen(in tens of thousands Address
information before the change in redof yen)(M)(D)
and after the change in blackandReasonRemarkssubmit it.

*Gender 1. Male

2. Female

1. Cohabitation
2. Living separately(Furigana)(Last name)ｍonthly
remuneration

Telephone number

タロウ

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

(Furigana)

Section for dependent

Address(First name)Kempo Hoken(D) Standard

Postal code 123-4567

Hanako(Last name)

Relationship

Date ofbirth

ハナコ(First name)Name

Name〇〇〇〇〇

Emp. No.

(Last name)(Furigana)

Section for dependent

100〇〇〇〇(M)(Y)

Date ofbirth(First name)

Name

(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 code
Human 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)

RequirementStudents 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