Column to be filled out by thehealth insurance society,000 yen (inthousands ofyen)Standard monthly
remuneration
Applicableclassification

Managing
director

Issuance date:

(Y)

(M)

(D)

Effective date:

(Y)

(M)

(D)

Clericalsupervisor

Person in charge

Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form

Current status of insured person*In order to pay the out-of-pocket limit at the counter, you need to apply to the health insurance society in advance and show your certificate before paying the medical expenses atthe counter.
*The issuance date of the certificate is set as the first day of the month to which the application date (date of receipt by the Health Insurance Society) belongs. Please consult with
the Health Insurance Society in urgent cases.

○○○○○

Furigana

ケンポ

Name ofinsured person○○○○○

Emp. No.

xxxxx Co., Ltd.

Name of affiliateddepartment

XXXX Department XXXX Section
Postalcode

Date of birth151

Telephonenumber:03(Telephone
number:03( ○○○○ )

○○○○)

0051

–Relationshipwith
the insuredperson

ケンポ イチロウ

Furigana

Ichiro Kempo○○○○(Y)Eldest son

Date of birth

2000(M)

01(D)

01–

Please write “same as above” if the addressis the same as the insured person
Telephonenumber:Usage□ Hospitalization care costs✔

Expected period ofhospitalizationor outpatient care

○○○○

(Y)

()

Outpatient care costs (including the dispensing of□ prescriptions)○(M)

For urgent cases → Request receipt by around

○

○○○○

(D) to(Y)(M)□✔ Address of the insured person
Desired destination
for sending theceiling-amountcertificate○○○○

X-X-X Sendagaya, Shibuya-ku, Tokyo

Postalcode

Address ofapplicableperson(D)タロウ

Name of affiliatedcompany

Name ofapplicableperson(M)

Taro Kempo

Address of theinsured person

Current status of applicable person

(Y)

100

Insurance card Codecode andnumberNumber

(D)

(Y)

○(M)

○(D)

*It may not be possible to meet your request depending on the transport conditions.

□ Address of the eligible person□ Other [Home / Hospital] *Please enter any necessary names (addressee/care of), room numbers, etc.
Postal code–If you selected “Other,” please write the desiredaddress for sending.
Please complete this section if the application is “toWas the injury caused by the actions of a third party (traffic accident, etc.)?
receive medical treatment for injury.”⇒ Yes /NoRemarks

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

A request is hereby made as detailed above for the issuance of an Eligibility Certificate for Ceiling-Amount.

To the Executive Head of the Accenture Health Insurance Society

Date of submission:
Date request received (stamp)

Labor and social security attorney submitting the application on behalf of the insured
20210401