Application Forms
Application Forms
Please download, print and use any relevant application form available here.
Forms Related to Application and Health Insurance Cards
| 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 |
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| Application Form for Reissue of Health Insurance Card (Card Loss/Damage) | PDF |
Completed Sample |
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| Request for Issuance of Maximum Co-payment Certificate for Health Insurance | Digital Application System |
EY Japan Health Insurance Society 〒100-0006 Tokyo Midtown Hibiya, Hibiya Mitsui Tower,1-1-2 Yurakucho, Chiyoda-ku, Tokyo |
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PDF |
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| Health Insurance Certificate of Application of Maximum Amount Notification of Loss | PDF |
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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 |
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| Application for Forfeiture of Status as an Insured Person with Optional Continued Insurance | PDF |
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Submission
for application
forms 1 through 4
for application
forms 1 through 4
Submission
for application
forms 5 through 9
for application
forms 5 through 9
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 (Print on A3-size paper.) |
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 |
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| 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 |
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| 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 |
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| Receipt statement B (internal medicine, surgery, ophthalmology, etc.) | PDF |
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| Consultation Details（Dental） | PDF |
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| Agreement of Authorization・Signature （Submission is indispensable.） |
PDF |
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| 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 |
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| Accident Report | PDF |
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| Written pledge | PDF |
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Submission
for application
forms 10 through 11
for application
forms 10 through 11
Submission
for application
forms 12 through 25
for application
forms 12 through 25
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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