PwC
Health Insurance Society

Application forms

* Check here for where to send the application form.

Health insurance eligibility and application-related forms

  • Please download the format from here and submit it on print.
  • * Do not download the form from here. Please apply on the HC web Service (Applying for Change of Personal Information) as instructed by the Human Resources Department. A complete set of required documents will then be sent to you by Otsuki Management & Labor Consulting Office. (This excludes Voluntarily and Continuously Insured Persons.)
form Example
Notice of dependent transfer * Example
Example 2 (remove)
Dependent charge sheet Example
Documents covering reason for application for dependent status Example
Insurance card/ Elderly beneficiary card Loss, destroyed and reissue application Example
Application for certificate to receive treatment for specific diseases and disorders Example
Request for Voluntary Continued Caverage Status Example
Notice of Disqualification for Voluntary Continued Caverage Status Example

Benefit and claims-related forms

  • Please download the format from here and submit it on print.
  • * Do not download the form from here. Please apply on the HC web Service (Applying for Change of Personal Information) as instructed by the Human Resources Department. A complete set of required documents will then be sent to you by Otsuki Management & Labor Consulting Office. (This excludes Voluntarily and Continuously Insured Persons.)
form Example
  •  There are two types of requests for issuing the Maximum Co-Payment Certificate for health insurance: electronic application and paper mail.
    Please apply by either method. In addition, ID and password are required for electronic application.

電子申請サービス

Application for Co-payments		 Example
Application Form for Medical Care Expenses Example
Detailed medical fee statement  
Attending Physician's Statement (for Overseas Medical Care Expenses)
Table for International Classification of Diseases for the use of Insurance (appendix)		  
Itemized receipt (for Overseas Medical Care Expenses)  
Attending Dentist's Statement (for Overseas Medical Care Expenses)  
Agreement of Authorization (for Overseas Medical Care Exenses or Overseas childbirth)  
Maternity Lump Sum Allowance/ Additional Maternity Lump Sum Allowance Application * Example
Maternity Lump Sum Allowance/ Additional Maternity Lump Sum Allowance Application (pre-applicatiopn) Example
Maternity Allowance Application * Example
Injury and Sickness Benefits Application Example
Application Form for Transportation Expenses Example
Claim for Funeral Expenses * Example
Notification of Succession of Rights  
Notice of accident involving bodily injury due to the actions of a third party  
Report on accident circumstances  
Written memorandum  
Written pledge  

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