Application forms | Procedures | Shiseido Health Insurance Society

Insurance card and application-related forms

form	example
「Notification of Health Insurance Dependent (Change) (for New Membership)」「Dependent Status」	Example（Join） Example
「Notification of Health Insurance Dependent (Change) (for Removal)」	Example（Delete）
「Health Insurance Card Return Sheet」
「Application Form for Reissue of Health Insurance Card (Card Loss/Damage/Full)」	Example
「Notification of Health Insurance Card Loss」	Example
「Health Insurance Dependent Residence Status Change Application」	Example
「Written Pledge (A): Unemployment Benefits」
「Written Pledge (B): Excess Annual Income」
「Written Pledge (B): Excess Annual Income (for those aged 60 and over and others)」
「Notification of Eligibility As Health Insurance Voluntarily and Continuously Insured Person」	Example
「Notification of Loss of Eligibility As a Voluntarily and Continuously Insured Person」	Example

form	example
「Application Form for Medical Care Expenses」	Example
「Application Form for Overseas Medical Care Expenses」	Example
「Application Form for Overseas Health Examination Expenses」
「Claim for Injury and Illness Allowance」	Example
「Injury and Sickness Allowance Claim Status Report (required document for first-time claimants)」
「Claim for Childbirth and Childcare Lump-sum Grant」	Example
「Claim for Childbirth and Childcare Lump-sum Grant (for Receipt on Your Behalf)」	Example
「Claim for Maternity Allowance」	Example
「Claim for Funeral Expenses」	Example
「Application Form for Approval of Transportation」
「Application Form for Transportation Expenses」
「Notification of Injury or Sickness Due to Third Party」
「Notice of cause of injury」
「Application Form for Insurance Benefits for One-car Accident」
「Notice of Eligibility for Medical Assistance (New/Renewal/Termination)」
「Application Form for Payment of Insurance Benefits」
「Request for Issuance of Maximum Copayment Certificate for Health Insurance」	Example
「Health Insurance Application Form for Certificate Issued for Specific Disease Treatmen」
「Application Form for Payment of High Aggregate Cost for Long-Term Care Service/Copayment Certificate」

form	example
「Application Form for Reimbursement of Smoking Cessation Treatment Costs」