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 | |
| Dependent Application: Required Documents Confirmation Chart （Add a dependent here） |
Required Documents | click here | |||
| Health Insurance Dependents (Change) Form【Removal】 | PDF |
－ | Completed Sample |
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| Employer's Certificate of Temporary Income Exceeds | PDF |
－ | － | ||
| Application for Name Change | PDF |
– | Completed Sample |
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| Application Form for Issue Eligibility Confirmation Document (Submission of No. 6 is not required if this form is submitted.) |
PDF |
EXCEL |
Completed Sample |
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| Report of Loss (Damage) of Eligibility Confirmation Document (If your Eligibility Confirmation Document is lost when retiring, transferring, continuing coverage voluntarily, or being removed as a dependent.) |
PDF |
– | Completed Sample |
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| Application form for canceling registration of the use of Individual Number Card as a Health Insurance card (Submission of No. 5 is not required if this form is submitted.) |
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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| Application for Issuance of Eligibility Certificate for Ceiling-Amount Application | 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 6
for application
forms 1 through 6
Submission
for application
forms 7 through 12
for application
forms 7 through 12
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 |
| Application for Injury and sickness allowance（Insured・Doctor） | PDF |
Completed Sample |
提出先はこちら | |
| Application for Injury and sickness allowance（Employer） | PDF |
－ | ||
| Application for Childbirth Allowance |
PDF |
Completed Sample |
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| Application 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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| Application 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 13 through 15
for application
forms 13 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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