Application forms

Health insurance eligibility and application-related forms

form	example	reference
”Application Form for Issue of eligibility Verification Certificate" "Application Form for Reissue of eligibility Verification Certificate" Example（Loss）	Example (loss) Example (Unnecessary for re-issue)	Reference
“Application Form for Certification as Voluntarily and Continuously Insured Person”	Example	Reference
“Application Form for Loss as Voluntarily and Continuously Insured Person”	Example	Reference
“Application Form for Adding a Dependent”		Reference

form	example	reference
"Application Form for Medecal Care Expenses (Temporary Payment)" "Receipts (A Detail) written opinion of medical doctor Statements (Doctors Proof)"	Example (Insured Person) Example (Dependents)	Reference
"Application Form for Medical Care Expenses (Orthosis・Therapeutic use Glasses)"	Example	Reference
"A Picture of Orthosis"		Reference
"Appication Form for Medical Care Expenses (Treatments for Acupuncture・Moxa cautery)"	Example	Reference
"Application Form for Medical Care Expenses (Japanese Traditional Massage or the other Massage)"	Example	Reference
“Claim for Injury and Sickness Allowance/ Additional Sum”	Example	Reference
“Claim for Childbirth and Childcare Lump-sum Grant/ Additional Sum”	Example	Reference
“Application for Payment of Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)”	Example	Reference
“Claim for Maternity Allowance”	Example	Reference
“Claim for Funeral Expenses/Funeral Costs”	Example of completed form (Insured Person) Example of completed form (Dependents )	Reference
“Request for issuance of Maximum Co-payment Certificate for Health Insurance”	Example	Reference
“Application Form for Issuance of Certificate of Receipt of Medical Expenses to Treat a Specified Disease”	Example	Reference