Information
Application
details on insured person

Injury and Sickness Benefits Application
Insurance cardcode and number

CodeNumber●●XXXXXXXX Co., Ltd., XXXX Branch

Name of affiliatedoffice/department

Name

Telephone number (ext.) 03-1234-5678(999）●● (Y) ●● (M) ●● (D)Date of birth

Taro Kempo〒123-4567
Address, telephone
number, etc. of applicant XXXX Condominium, #456 1-2-3 XXXX-cho, XXXX Ward, Tokyo(daytime phone number)
Telephone number 03-7891-2345

1234567

Employee ID number1)
Name of injury /illness2)

XXXX＠XXXX.ne.jp

E-mail address

Right thigh fracture
Date of injury
or onset of illness

Right istal radius fracture

●(Y)

●(M)

● (D)

●(Y)

●(M)

● (D)

(M)

(D)

3)

(Y)

Cause of injury
or illness

Was the need for
medical carecaused by a thirdparty(traffic accident,Period taken off
due to injury/illness

Lost footing and fell down the stairs at home
No/Yes※If the answer is "yes," a separate notification is required.

● (Y) ●● (M) ●● (D)Was the need for
medical carecaused by to workor on the way towork?

No/

Yes

※If the answer is "yes," a separate notification is required.

● (Y) ●● (M) ●● (D)toDid you receive remuneration during the period taken off due to injury/illness?
Or, will you receive remuneration in the future?

31
No/daysYes

If you answered “Yes” above, please enter the remuneration payment period and remuneration amount below.
Remuneration
payment period

May 2, XXXXyen

May 10, XXXX

to9

days

Currently receiving / Currently requesting /Neither■ Are you currently receiving or requesting disability pension/disability allowance, old-age pension, etc.?
If you answered “Currently receiving” or “Currently requesting,” please complete the following section.
Type of pension, etc.

1. Disability pension 2. Disability allowance 3. Old-age pension 4. Other (Currently receiving / Currently requesting /NeitherName of injury /illness

Pension amountBasic pension number

Date on which payment
commenced■ Are you currently receiving or claiming temporary disability compensation from unemployment insurance orworker's accident compensation insurance?
Type of benefit

1.unemployment benefit 2.Compensation benefits for absence from work()

(Y)

(M)

(D)

Currently receiving / Currently requesting /Neither
Labor Standards Inspection Office) 3.Other()

Remarks

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 numberBank NumberBank

Name of financial
institution
Type of accountDate:Central branchbranchShinkin bank(credit treasury)
Savings accountChecking accountName of account

Other()

Account number

holder(Katakana)

Individual number (not required when entering the code and number from the insured
person's card)

Date request received(stamp)*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

Accenture Health Insurance Society1（20220401）

■ Please obtain an opinion and certification from the attending physician.
Date of injury
or onset of illness

(Y)

(M)

(D)

1)

(Y)

(M)

(D)

2)

treatment began
Please ask the attending
physician (Y)(Y)
to complete this section

(M)

(D)

(M)

(D)

Name of patient

Name of injury /illness

Date medical

Opinion of the attending physician3)
Cause of injury
or illness
Period during which
the inability to work
has been recognized

(Y)

(M)

(D)

(Y)

(M)

(D)

todaysIf hospitalized, period ofthat hospitalization

(Y)

(M)

Main symptoms of injury/illness, progresssummary, treatment details, etc.
Medical opinion that recognized that work
carried out before then could no longer be
carried out (based on course of symptoms)
I hereby certify that the above is true and correct.

(D)

to(Y)

(M)

Actual numberof days of
medicaltreatment

(D)

(D)

days

Address of medicalinstitution

Date

Name of medical institution

Name of physician■ Please obtain a certificate from your employer.

Column to be certified by the employer

Name of insured
personWork status (use the following symbols: “〇” for days worked, “△” for paid vacation, “H” for national holidays, and “/” for absences)

Days
workedPaidvacation

Please ask the employer for acertificate for this section

(Y)

(M)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(D)

(D)

(Y)

(M)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(D)

(D)

(Y)

(M)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(D)

(D)

Did you receive (will you receive) wages for the period listed
above?
Monthly salaryYes /End ofpayment
periodNo

Monthly salary based ondaily accumulated salary

Daily salaryType of salary
Hourly wage

Percentage wage

Other (Date ofpayment)

Payment period
Compensation paid
for the period above(salary, benefits, etc.)

Calculation ofwages(D)□Applicablemonth(D)□ Next month

Payment amount

Date of payment

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

(Y)

(M)

(D) to(Y)

(M)

(D)

yen

(M)

(D)

If no payment has been madeup to now and will not bemade in the future, state thereason
Method for calculation ofwages(deduction for absences, etc.)

I hereby certify that the above is true and correct. Office address
Date

Name of office
Name of employer[To employers]● Please enter the working status, wage payment status, etc., for the wage calculation period, including the period when you did not work.
● You do not need to enter the work status if a copy of your attendance record is attached.
● Please attach a copy of your payroll book.
Accenture Health Insurance Society2（20220401）