PwC
Health Insurance Society

Application forms

* Check here for where to send the application form.

Lists

Insurance card and application-related forms
Benefit and claims-related forms

Insurance card 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
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. 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