Application forms

• Notification of Health Insurance Dependent (Change) (Addition/Removal) on MY HEALTH WEB)
• Documents to be submitted to the health insurance association via the company (Group HR & Administrative Service Department　Social Insurance in charge)
• Documents to be submitted directly to the health insurance association

Notification of Health Insurance Dependent (Change) (Addition/Removal) on MY HEALTH WEB 

Purpose	Application method
Increase in number of dependents Decrease in number of dependents	Log in toMY HEALTH WEB <JAPANESE> and apply from the Notification of Health Insurance Dependent (Change) (Addition/Removal). ＊If the number of dependents has increased, see “Documents required when applying for dependent certification” and prepare all required documents before applying. ＊Be sure to return the health insurance card(s),etc if the number of dependents has decreased.

Documents to be submitted to the health insurance association via the company (Group HR & Administrative Service Department　Social Insurance in charge)

Submit to:	By post： Endo Labor Management Office, attn.: Social Insurance 1-2-30 Sanarudai, Chuo-ku, Hamamatsu-shi, Shizuoka Prefecture 432-8021	However, if your health insurance code is 3001 or higher, submit to your employer's HR staff.
	By interoffice mail： SBU, Group HR & Administrative Service Department (in charge of Social Insurance) (ELO)

Purpose	Title	Application form	Excel Word	Example
Change/correction of dependent’s name/date of birth	Notification of Change/correction in Dependent Name/Date of Birth	Form	Excel	Example <English>
If the insured person is without pay during time off from work for childbirth	Claim for Maternity Allowance	Form	Excel	Example <English>
If the insured person is without pay during time off from work resulting from illness/injury	Application for Injury and Illness Allowance plus Additional Sum	** The application form will be distributed by each company’s HR department prior to start of absence.
If the insured person is without pay during time off from work resulting from illness/injury	Status Report submitted at time of first claim	** The application form will be distributed by each company’s HR department prior to start of absence.

Documents to be submitted directly to the health insurance association

Submit to:	By post： Suntory Health Insurance Association 2-1-40 Dojimahama, Kita-ku, Osaka 530-0004
	By interoffice mail： Health Insurance Association, Suntory Osaka Office

Purpose	Title	Application form	Excel Word	Example
Issuing/Reissuing an Eligibility Verification Certificate	Application Form for Issue/Reissue of Eligibility Verification Certificate	Form	Excel	Example <English>
Unable to return health insurance card, etc.	Notification of Loss of Health Insurance Card	Form	Excel	Example <English>
When you want to reduce the amount of medical care costs you pay at the medical care institution because you expect to incur high medical care costs	Certificate of Application of Maximum Copayment Amount	Form	Excel	Example ＜English>
If you paid the entire medical care cost up front because you were unable to present your myna health insurance card	Application Form for Medical Care Expenses (because myna health insurance card not presented or related reasons)	Form	Excel	Example <English>
If you ordered custom prosthetic equipment	Application Form for Medical Care Expenses (for prosthetic equipment)	Form	Excel	Example <English>
If you ordered prescription eyeglasses or contact lenses	Application Form for Medical Care Expenses (for prescription eyewear ･ contact lenses)	Form	Excel	Example <English>
Childbirth by insured person/dependent family member	Claim for Childbirth and Childcare Lump-sum Grant	Form	Excel	Example <English>
First child born to insured person/dependent family member	Request for Distribution of Childcare Book	Form	Word	Example
If you received treatment overseas	Application Form for Overseas Medical Care Expenses	Form	Excel	Example <English>
If you received treatment overseas	Attending physician’s statement (Form A)	Form	-	-
If you received treatment overseas	Attending dentist’s statement (Form C)	Form	-	-
If you received treatment overseas	Itemized receipt (Form B)	Form	-	-
If you received treatment overseas	Letter of Consent to Investigation	Form	Word	Example
When your doctor states that transportation is necessary to or between hospitals【For prior approval】	Application Form for Approval of Transportation	Form	Excel	Example <English>
When your doctor states that transportation is necessary to or between hospitals【To claim expenses】	Application Form for Transportation Expenses	Form	Excel	Example <English>
Death of insured person/dependent family member	Claim for Funeral Expenses	Form	Excel	Example <English>
If you receive treatment for chronic renal insufficiency or hemophilia requiring dialysis	Application Form for Certificate Issued for Specific Disease Treatment	Form	Excel	Example <English>
Remaining a member of the Health Insurance Association after you leave your employer	Notifications regarding Voluntarily and Continuously Insured Person	Form	Excel	Example <English>
Name change while Voluntarily and Continuously Insured Person after leaving former employer	Notification of Name Change for Voluntarily and Continuously Insured Person	Form	Excel	Example