Application Forms
Application Forms
Please download, print and use any relevant application form available here.
Forms Related to Application, a Health Insurance Card and an Eligibility Confirmation Document
| No. | Application Form | Document | Completed Sample | Submission | |
| Notification of Health Insurance Dependent (Change) | PDF |
– | Completed Sample |
click here | |
| Dependent Application | PDF |
– | Completed Sample |
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| Dependent Certification Check Sheet | PDF |
– | – | ||
| list of documents required for dependent certification | PDF |
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| Petition for reasons for delay （If there is a delay of 3 months or more from the date of occurrence of the event） |
PDF |
– | – | ||
| Report of loss (damage) of health insurance card | PDF |
– | Completed Sample |
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| Application Form for Issue Certification of Health Insurance Eligibility (Only insured persons and dependents who acquired eligibility on or after December 1, 2024 may apply.) |
PDF |
EXCEL |
Completed Sample |
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| Application form for canceling registration of the use of Individual Number Card as a Health Insurance card | PDF |
－ | － | EY Japan Health Insurance Society 〒100-0006 Tokyo Midtown Hibiya, Hibiya Mitsui Tower,1-1-2 Yurakucho, Chiyoda-ku, Tokyo |
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| Request for Issuance of Maximum Co-payment Certificate for Health Insurance | Digital Application System |
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PDF |
– | – | |||
| Application for Reissuance of Health Insurance Certificate of Application of Maximum Amount Notification / Elderly beneficiary card Due to Loss/Damage | PDF |
– | Completed Sample |
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| Request for Issuance of Certificate Issued for Specific Disease Treatment | PDF |
– | Completed Sample |
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| Application Form for Certification as Voluntarily and Continuously Insured Person | PDF |
– | – | ||
| Application for Forfeiture of Status as an Insured Person with Optional Continued Insurance | PDF |
– | – | ||
Submission
for application
forms 1 through 7
for application
forms 1 through 7
Submission
for application
forms 8 through 13
for application
forms 8 through 13
EY Japan Health Insurance Society
〒100-0006
Tokyo Midtown Hibiya, Hibiya Mitsui Tower, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo
〒100-0006
Tokyo Midtown Hibiya, Hibiya Mitsui Tower, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo
Forms Related to Benefits
| No. | Application Form | Document | Completed Sample | Submission |
| Claim for Injury and Sickness Allowance (Print on A3-size paper.) |
PDF |
Completed Sample |
click here | |
| Claim for Maternity Allowance |
PDF |
Completed Sample |
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| Claim for Funeral Expenses/Additional Sum |
PDF |
Completed Sample |
EY Japan Health Insurance Society 〒100-0006 Tokyo Midtown Hibiya, Hibiya Mitsui Tower,1-1-2 Yurakucho, Chiyoda-ku, Tokyo |
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| Claim for Childbirth and Childcare Lump-sum Grant/Additional Sum | PDF |
Completed Sample |
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| Application for Payment of the Childbirth and Childcare Lump-sum Allowance (Substitute Payee System) | PDF |
– | ||
| Application Form for Medical Care Expenses | PDF |
Completed Sample |
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| Overseas provision written application of medical expenses * If you are an expatriate, please apply through your employer. |
PDF |
Completed Sample |
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| Consultation Details Form A (e.g., Internal Medicine, Surgery, Ophthalmology) |
PDF |
– | ||
| Table of International Classification of Diseases for the use of Social Insurance * Please refer to should you need to prove the social insurance International Classification of Diseases number. |
PDF |
– | ||
| Receipt statement B (internal medicine, surgery, ophthalmology, etc.) | PDF |
– | ||
| Consultation Details（Dental） | PDF |
– | ||
| Agreement of Authorization・Signature （Submission is indispensable.） |
PDF |
– | ||
| Voyage confirmation document （A copy of the page on your passport where you can confirm your name and date of arrival and departure） |
Submission is unnecessary for overseas assignment, an overseas business trip and overseas training in case of a work order. | |||
| Notice of Bodily Injury due to Actions of a Third Party *In the case of a traffic accident, an accident certificate is also required. |
PDF |
– | ||
| Accident Report | PDF |
– | ||
| Written pledge | PDF |
– | ||
Submission
for application
forms 14 through 15
for application
forms 14 through 15
Submission
for application
forms 16 through 29
for application
forms 16 through 29
EY Japan Health Insurance Society
〒100-0006
Tokyo Midtown Hibiya, Hibiya Mitsui Tower, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo
〒100-0006
Tokyo Midtown Hibiya, Hibiya Mitsui Tower, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo
Forms Related to Healthcare Services
| No. | Application Form | Document | |
| Application for Subsidy of Influenza Vaccination Cost | Digital Application System |
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