Application forms
Caution for submitting documents
- Print out all relevant pages on A4 paper.
- Forms marked with a “★” can be filled out in PDF.
If you cannot select the PDF radio buttons, please save the file to your desktop, and then use it.
- Health insurance eligibility and application-related forms
- Benefit and claims-related forms
- Health activities-related forms
- Other forms
- Employers-related forms
Health insurance eligibility and application-related forms
Insurance Card
| Form | Sample | Submit to: | |
|---|---|---|---|
| Application Form for Reissue of Health Insurance Card (Card loss) | ★ | Sample | Your employer's HR section |
Dependent
| Form | Sample | Submit to: | |
|---|---|---|---|
| Notification of Health Insurance Dependent (Change) | ★ | Sample | Your employer's HR section |
| Notification of Situation of Health Insurance Dependent (Spouse / Children) (18 years old or over) | ★ | Sample | Your employer's HR section |
| Notification of Situation of Health Insurance Dependent (Excluding Spouse / Children) (18 years old or over) | ★ | Sample | Your employer's HR section |
|
Written Pledge Regarding Income Written Pledge Regarding Income |
★ | Your employer's HR section | |
|
Written Pledge Regarding Remittance Written Pledge Regarding Remittance |
★ | Your employer's HR section | |
Voluntarily and Continuously Insured Person
| Form | Sample | Submit to: | |
|---|---|---|---|
| Application Form for Certification as Voluntarily and Continuously Insured Person * The form can be attached to an e-mail to apply. |
★ | Sample | Pfizer Health Insurance Society |
| Notification of Change of Voluntarily and Continuously Insured Person | ★ | Sample | Pfizer Health Insurance Society |
| Notification of Disqualification as Voluntarily and Continuously Insured Person (Refund Claim) | ★ | Sample | Pfizer Health Insurance Society |
Long-term Care Insurance
| Form | Sample | Submit to: | |
|---|---|---|---|
| Notification of Long-term Care Insurance (Qualification/ Disqualification) | ★ | Sample | From your employer to Pfizer Health Insurance Society |
Benefit and claims-related forms
Benefit
Childbirth, Death
| Form | Sample | Submit to: | |
|---|---|---|---|
| Application Form for Maternity Allowance | ★ | Sample | Your employer's HR section |
| Application Form for Childbirth and Childcare Lump-sum Grant (Additional Sum) * Provide copies of detailed receipts of childbirth costs with the stamp of the maternity medical care compensation scheme |
★ | Sample | Your employer's HR section |
| Application Form for Loan of Childbirth Expense | ★ | Sample | Pfizer Health Insurance Society |
| Deed of borrowing of Childbirth Expense | Sample | Pfizer Health Insurance Society | |
| Claim for Funeral Expenses (Additional Sum) | ★ | Sample | Company or Health Insurance Society |
Health activities-related forms
| Name of Application Forms | Submit to: |
|---|---|
|
The method for applying for subsidies through KENPOS changed on October 1, 2017. For flu vaccines, you can also take advantage of the Toshinkyo vaccination program, which does not require payment at the reception desk. Please be sure to do so. You can get vaccinated simply by bringing your "voucher" and "insurance card" on the day of the vaccination. The Toshinkyo vaccination process |
| Form | Sample | Submit to: | |
|---|---|---|---|
|
Application Form for the cost of Stop-Smoking Treatment Application Form for the cost of Stop-Smoking Treatment |
★ | Sample | Pfizer Health Insurance Society |
Other forms
| Form | Sample | Submit to: | |
|---|---|---|---|
|
Application Form for Issue of Medical Care Cost Information Application Form for Issue of Medical Care Cost Information |
★ | Sample | Pfizer Health Insurance Society |
| Notification of Benefit Transfer Account Change after leaving | ★ | Sample | Pfizer Health Insurance Society |
Employers-related forms
| Form | Sample | Submit to: | |
|---|---|---|---|
| Notification of Name Change (Correction) of Insured Person | ★ | From your employer to Pfizer Health Insurance Society | |
| Notification of Birth Date Correction of Insured Person (Processing slip) | ★ | From your employer to Pfizer Health Insurance Society | |
| Notification of Health Insurance Card Nonrecoverable | ★ | From your employer to Pfizer Health Insurance Society | |
| Report on Health Service Costs | ★ | From your employer to Pfizer Health Insurance Society | |