IHG ANA Hotels Health Insurance Association

IHG ANA Hotels Health Insurance Association

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Application forms

Health insurance eligibility and application-related forms

To members:
Submit all documents to your employer’s HR section. Obtain forms in duplicate format (carbon paper) and forms not shown in the table below from your employer’s HR section.

form Example of completed form (for staff use) Example of completed form (for member use)
❶Forms related to childcare leave (templates)
1 “Application for Maternity Leave” Example ―
2 “Maternity Leave Change (Termination) Notice” Example ―
3 “Notice of Change in Monthly Remuneration upon End of Maternity Leave” Example ―
4 “Application for Childcare Leave” Example ―
5 “Childcare Leave Ending Notice” Example ―
6 “Notice of Change in Monthly Remuneration upon End of Childcare Leave” Example ―
❷Forms related to calculations and related topics
7 “Calculation Summary Sheet” ― ―
8 “Calculation Summary Sheet (sample)”
Contact the Health Insurance Association (attn.: Coverage) if you need this form.		 ― ―
9 “Notice of Bonus Payment Summary Sheet” ― ―
10 “Notice of Monthly Change Summary Sheet” ― ―
11 “List of Supplemental Materials for Magnetic Medium Notices of Calculation” ― ―
❸Notices of eligibility/loss of eligibility (templates)
12 “Notification of Eligibility” ― ―
13 “Notification of Loss of Eligibility” ― ―
❹Forms related to eligibility, insurance cards, and related topics
14 “Notification of Name Change (Correction) of Insured Person”
“Notification of Name Change (Correction) of Insured Person”		 Example ―
15 “Notification for Birth Date Change of Insured Person” Example ―
16 “Notification of Change (for use by insured person/Voluntarily and Continuously Insured Person)”
“Notification of Change (for use by insured person/Voluntarily and Continuously Insured Person)”		 ― ―
17 “Retirement Status Confirmation Form” ― To obtain the form, contact HR.
18 “Dependent Confirmation Form” ― To obtain the form, contact HR.
19 “Written Pledge of No Employment/Income” Example Example
To obtain the form, contact HR.
20 “Statement of Reasons for Delay in Submitting Notification of Change” Example Example
To obtain the form, contact HR.
21 “Certificate Issuance Application (for use by insured person/Voluntarily and Continuously Insured Person)” ― To obtain the form, contact HR or the Health Insurance Association (attn.: Coverage).
22 “Insured Person Certificate (for Health Insurance Association use)” ― ―
23 “Report on Non-collection of health Insurance Card and Eligibility Verification Certificate”
“Report on Non-collection of health Insurance Card and Eligibility Verification Certificate”		 ― ―
24 “Report on Delay in Procedures” Example ―
25 “Notification of Health Insurance Card and Eligibility Verification Certificate Loss” *Used to have a new Eligibility Verification Certificate issued ― ―
26 “Written Explanation (of Loss of Health Insurance Card): Sample explanation for reference” Example ―
27 “Notification of Health Insurance Card and Eligibility Verification Certificate Nonrecoverable” ― ―
28 “Application Form for Reissue of Notice of Eligibility Information (Loss/Damage)”
“Application Form for Reissue of Notice of Eligibility Information (Loss/Damage)”		 ― ―
29 “Application Form for Reissue of Eligibility Verification Certificate(Loss/Damage)”
“Application Form for Reissue of Eligibility Verification Certificate(Loss/Damage)”		 ― ―
30 “Application Form for Certification as Voluntarily and Continuously Insured Person”
“Application Form for Certification as Voluntarily and Continuously Insured Person”		 ― ―

Benefit and claims-related forms

form Example of completed form (for staff use) Example of completed form (for member use)
1 “Request for Issuance of Maximum Co-payment Certificate for Health Insurance (for use by insured person/Voluntarily and Continuously Insured Person)“ ― To obtain the form, contact HR or the Health Insurance Association (attn.: Coverage).
2 “Claim for Childbirth and Childcare Lump-sum Grant“ ― ―
3 “Claim for Maternity Allowance/ Additional Sumc“（A3） ― ―
4 “Claim for Injury and Sickness Allowance”（A3） ― ―
5 “Personal Status Report / Agreement“ ― ―
6 “Agreement“ ― ―
7 “Application Form for Medical Care Expenses“（A3） ― ―
8 “Application Form for Overseas Medical Care Expenses, itemized receipt, etc.“ ― ―
9 “Application Form for Approval of Transportation/Notification of Transportation (for patients with serious conditions)“ ― ―
10 “Application Form for Transportation Expenses (for patients with serious conditions)“ ― ―
11 “Application Form for Certificate Issued for Specific Disease Treatment“ ― ―
12 “Claim for Funeral Expenses“ ― ―
13 “Notification of Loss of Certificate of Application of Maximum Copayment Amount“ ― ―

Health activities-related forms

form Example of completed form (for staff use) Example of completed form (for member use)
1 “Application Form for implementation approval“
“Subsidy Application Form for Examination for Lifestyle-Related Conditions“		 ― ―
2 “Vaccination Subsidy Application Form“ ― ―
3 To apply for a contracted institution complete check-up, go here. ― ―
4 “Complete Check-up Application /Subsidy Application Form *Non-Contracted Institution“ ― ―
5 “Gynecological Examination Subsidy Application Form“ ― ―
6 “Brain Examination (Brain Checkup) Application/Subsidy Application Form“ ― ―
7 “Outpatient Smoking Cessation Treatment Application/Subsidy Application Form“ ― ―

Other forms

form Example of completed form (for staff use) Example of completed form (for member use)
❶Third-party acts
1 “Notification of Injury or Sickness due to a Third-party Act“ ― ―
2 “Accident Report“ ― ―
3 “Letter of Consent“ ― ―
4 “Completion of Treatment Report“ ― ―
❷Notices related to establishment (address, name, employer, etc. change/correction)
5 “Notice of Change (Correction) to Address/Name of Eligible Establishment“ ― ―
6 “Notice of Change (Correction) Regarding Eligible Establishment“
*When changing employer (agent)		 ― ―

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