Application form lists

Childbirth/Death/Other benefit application

form Sample
Application Form for Medical Care /ExpensesDetails of treatment
Application Form for Medical Care Expenses (acupuncture) *Claim to Health Insurance Association
Application Form for Medical Care Expenses ( moxibustion/massage) *Claim to Health Insurance Association
Claim for Injury and Illness Allowance *Submit both sheets.
Claim for Injury and Illness Allowance (for continuing benefits) *Submit both sheets.
Claim for Maternity Allowance
Application for Payment of Childbirth and Childcare Lump-sum Grant
Claim for Funeral Expenses
Application Form for Transportation Expenses
Application Form for Overseas Medical Care Expenses
(Since this form is a five-sheet carbon-copy form, it is not available to download. Request it from the Health Insurance Association.)
Notification of Injury or Illness due to a Third-party Act(page1)
Notification of Injury or Illness due to a Third-party Act(page2)*Submit both sheets. Attach the Written pledge below
Written pledge
Request for issuance of Maximum Co-payment Certificate for Health Insurance Sample

When examination in the health insurance association is completed, the benefit mentioned above is transferred to the company in a total around 24th of the next month on the end of the month. The personal payment is transferred to the registered bank account.
If you apply using just your Social Security and Tax Number, you will be required to submit additional documents. Consult with the Association in advance. If you enter your Health Insurance Card Symbol and Number, you do not need to indicate your Social Security and Tax Number.