List of application documents
Various notification forms and entry examples
On this page, you can download various notification forms (Excel files).
You can fill in the printed version by referring to the example, or you can fill it out directly in the file and submit the printed version. Adobe (R) Acrobat (R) Reader is required to see the entry example. If you do not have it, click the icon on the right to download it.
- Application(voluntary continuous insured qualification acquisition application, dependent (transfer) notification, reissuance application, etc.)
- Benefits(injury and illness allowance bill, lump-sum birth and childcare bill, medical treatment fee application, etc.)
- Health business(general health examination bill, etc.)
Application
| Number | Name | Download entry example |
|---|---|---|
| Application-2-① | Notification of dependents of health insurance (transfer) (primary / secondary) (A4) | Excel List of attached documents Entry example |
| Application-2-② | Pledge regarding about unemployment and no income | Excel Entry example |
| Application-2-③ | Pledge regarding unemployment insurance | Excel Entry example |
| Application-2-④ | Certificate of expected annual income | Excel Entry example |
| Application-3 | Dependent Status Table (A4) | Excel Entry example |
| Application-4 | Notification of loss of health insurance card (A4) | Excel Entry example |
| Application-5 | Notification of non-collection of health insurance card (A4) | Excel Entry example |
| Application-6 | Health insurance card (loss / damage / no margin) reissue application (A4) | Excel Entry example |
| Application-11 | Health insurance limit application certification application (A4) | Excel Entry example |
| Application-12 | Application for Health Insurance Limit Application / Standard Burden Reduction Certification (A4) ※Municipal tax exemption persons, etc. |
Excel Entry example |
| Application-13 | Application form for issue of Certificates Issued for Specific Disease Treatment（A4） | Excel Entry example |
Benefits
| Number | Name | Download entry example |
|---|---|---|
| Benefits-1 | Insured person / family medical expenses payment application (A4 × 2) | Excel Entry example |
| Benefits-2 | Insured person / family medical expenses payment application "overseas" (A4) | Excel |
| Benefits-3 | Injury and illness allowance bill (A4x2) |
Excel
Fujisoft Incorporated employees please click here Entry example |
| Benefits-3-① | Recuperation status / Daily life status petition (A4) | Word |
| Benefits-4 | Childbirth allowance bill (A4) | Excel Entry example |
| Benefits-5 | Insured person / family childbirth and childcare lump sum payment / surcharge bill (A4) ≪For those who do not use the direct payment / receipt agency system≫ |
Excel Entry example |
| Benefits-5-② | Insured person / family childbirth and childcare lump-sum payment / additional payment (Internal payment) Invoice (For direct payment system) (A4) ≪Those who use the direct payment system≫ |
Excel Entry example |
| Benefits-5-③ | Insured person / family childbirth and childcare lump sum payment / surcharge bill (For receiving agency system A4) ≪Those who use the receiving agency system≫ |
Excel Entry example |
Health business
| Number | Name | Download entry example |
|---|---|---|
| Health insurance-1 | General health examination bill (A4) | Excel Entry example |
| Health insurance-2 | Lifestyle-related disease examination bill (A4) | Excel Entry example |
| Health insurance-3 | Human Dock bill (A4) | Excel Entry example |
| Health insurance-4 | Brain examination bill (A4) | Excel Entry example |
| Health insurance-5 | Gynecological examination bill (A4) | Excel Entry example |