Claim for Health Insurance Payment of Funeral Expenses (Costs)additional benefits
for Insured Person or Family Member
CodeApplicant information

Insurance cardcode and number

NumberName of affiliatedoffice/department(Ext.

Applicant date ofbirth

Name of applicant
Address, telephone
number, etc. of applicant(daytime phone number)Phone number)
(Y)

(M)

(D)

〒
Phone number

Employee ID
number(Ext.

)

E-mail address

Date of death

(Y)

(M)

(D)

Was it caused by theactions of a third party?

Cause of deathYes /No

Relationshipwith the(M)(D)
insuredperson
Name ofinsurer
Phone number(■ For application submitted upon the death of a family member (a dependent)

Application details

Name of family
memberDate of birth(Y)

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.
(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 healthinsurance 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

Code andnumber■ For application submitted upon the death of the insured person
Name of insured
personPersonal relationship between
the insured person andapplicantDate offuneral

BurialexpensesIf you fall under one of the following categories, please enter name of the insurer and the code and number of the health insurance inwhich the deceased had been enrolled after retirement.
(1) Died within 3 months after being disqualified from this health insurance due to retirement, etc.
(2) Died while continuing to receive the injury/illness allowance or maternity allowance from this health insurance society after being
disqualified(3) Died within 3 months after the end of receiving (2) after being disqualified

Column to be certified bythe business owner)

Name ofthe deceasedyenName ofinsurer

Phone number()Code andnumber

Insured person or dependent

Date of death

Insured person / Dependent
I hereby certify that the above is true and correct.

(Y)(M)

(D)

(Y)

(M)

(D)

Office address
Name of office
Name of employer

Telephone number()

Information on transfer
destination

Authorization Letter*If you wish to delegate receipt, please complete the authorization letter.
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)

Name

Branch number

Bank Number

Name of financial
institution
Type of account

Date:

Savings accountChecking accountBank

Central branch

Shinkin bank(credit treasury)

branchOther()

Account
numberName ofaccount holder(Katakana)Remarks

Individual number (not required when entering the code and number from the insured person'scard)*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 behalfof the insured

Date request received(stamp)Accenture Health Insurance Society(20220401)