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

＊Click here to check your Code and Number.
Please do not enter your Individual Number (My Number) on any application forms.

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

If you wish to remain a member of the Health Insurance Society

Required documents:
  • Direct Debit Authorization Form
Deadline: Within 20 days after the date of loss of eligibility of the insured person
Applies to: Insured persons who have been insured continuously for at least two months prior to leaving employment
Submission destination Send the application form
Notes: Please mail the Application Form for Certification as Voluntarily and Continuously Insured Person directly to the PwC Health Insurance Society.

How to apply for a Certificate of loss of eligibility

Name of the document:
  • Certificate of Loss of Eligibility
How to apply:
Who can apply?: Insured persons or dependents who have lost eligibility
Certifier: PwC Health Insurance Society
Notes: Please apply after you have lost the eligibility.

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

＊Click here to check your Code and Number.
Please do not enter your Individual Number (My Number) on any application forms.

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  
Notification of Injury or Sickness Due to a Third-Party Act (Traffic Accident)  
Report on accident circumstances(Traffic Accident)  
Written Memorandum (for the Other Party)  
Written Memorandum (for the Insured Person)  
Reason for Failure to Obtain a Certificate of the Personal Injury Accident  
Notification of Injury or Sickness Due to a Third-Party Act  
Report on Accident Circumstances(for Accidents Other Than Traffic Accidents)  
Written Memorandum (for the Other Party)  
Written Memorandum (for the Insured Person)  

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