If you lose your Health Insurance Card, etc.

Application for Reissue of Health Insurance Card (Notice of Lost Card)

Sample completed form

＜Identification Documents＞
Attach either of the following documents:

1. A copy of an identification document verifying the identity of the insured person (e.g., driver's license, passport, employee ID).
   A document verifying the identity of the insured person is required even when the application is submitted for a dependent's health insurance card.
2. A copy of the proof of notification of police

Application for Reissue of Health Insurance Card (Notice of Lost Card)

Sample completed form

Documents to attach:

• Damaged Health Insurance Card

Identification Documents
You may be asked to attach the following documents or document copies to verify the applicant’s identity.

1. An identification document showing a facial photograph of the applicant (e.g., driver’s license, passport). If the applicant does not have picture ID, an official certificate such as a certificate of residence.
2. If somebody else is applying on your behalf, documentation of the relationship between you and the person applying, in addition to the ID of the person applying, etc.

• Notification of Loss of Certificate of Application of Maximum Copayment Amount
• Sample completed form

〒103-0015
10F, Daiwa River Gate South Wing,
36-2, Nihonbashi, Hakozaki-cho,
Chuo-ku, Tokyo

IBM Japan Health Insurance Association

• If you later find the lost Certificate of Application of Maximum Copayment Amount, promptly return it to the Health Insurance Association.
• If you would like your Certificate of Application of Maximum Copayment Amount to be reissued, submit the Request for Issuance of Maximum Copayment Certificate for Health Insurance again.