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List of application forms
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List of application forms

Forms related to health insurance cards and eligibility

Title of formDownload
notice/application form		Download example of
completed notice/form
Application Form for Reissue of Health Insurance Card (Card loss/Damage)FormExample of completed form
Notification of Health Insurance Card LossFormExample of completed form
Notification of Loss of Eligibility as Health Insurance DependentFormExample of completed form
Notification of Loss of Eligibility as Health Insurance Dependent (for period of receipt of unemployment benefits)FormExample of completed form
Application Form for Dependent CertificationFormExample of completed form
Unemployment Benefits Receipt Confirmation FormFormExample of completed form
Unemployment Benefits Waiver Confirmation Form.FormExample of completed form
Survey Form of Livelihood Dependency on Insured PersonFormExample of completed form
Notice of Change to Registered Health Insurance InformationFormExample of completed form
Application Form for Certification as Health Insurance Voluntarily and Continuously Insured PersonFormExample of completed form
Notification of Long-term Care Insurance (Qualification/Disqualification) (Insured Person)FormExample of completed form
Application form for reissue of specified health diagnosis examination ticket/health guidance ticketFormExample of completed form

Forms related to benefits and claims

Title of formDownload
notice/application form		Download example of
completed notice/form
Claim for Medical Care Expenses (Insured Person, Dependent)FormExample of completed form
Letter of Consent to InvestigationForm-
Dental consultation details (for dental care)Form-
Medical consultation details (for non-dental care)Form-
Itemized receiptForm-
Request for issuance of Maximum Co-payment Certificate for Health InsuranceFormExample of completed form
Application Form for Approval of TransportationFormExample of completed form
Application Form for Transportation ExpensesFormExample of completed form
Claim for Injury and Sickness Allowance/Additional SumFormExample of completed form
Claim for Maternity Allowance/Additional SumFormExample of completed form
Claim for Childbirth and Childcare Lump-sum Grant (Insured Person, Dependent)FormExample of completed form
Claim for Funeral Expenses/Funeral Costs (Insured Person, Dependent)FormExample of completed form
Application for Payment of High Aggregate Cost for Long-Term Care ServiceFormExample of completed form
Application Form for Issuance of Copayment Certificate (Aggregation for Long-Term Care Service for the Aged)FormExample of completed form
Health Insurance Application for Payment of Benefits (Outpatient Annual Aggregate)/Issuance of Copayment Certificate for
High-cost Medical Expenses 		FormExample of completed form
Application Form for Certificate Issued for Specific Disease TreatmentFormExample of completed form

Forms related to third-party actions (including traffic accidents)

Title of formDownload
notice/application form		Download example of
completed notice/form
Notification of Injury or Sickness due to a Third-party Act FormExample of completed form
Written PledgeFormExample of completed form
Interim Report on Traffic AccidentFormExample of completed form
Notice of Completion of TreatmentFormExample of completed form
Application Form for Exemption from Refunding of Insurance BenefitsFormExample of completed form

Forms related to traffic accidents caused by your own negligence

Title of formDownload
notice/application form		Download example of
completed notice/form
Notice of Accident Due to Own NegligenceFormExample of completed form
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