Application Forms

Please download, print and use any relevant application form available here.

Enrollees with HGST Japan, Ltd.
No. Application Form Document Entry
Sample
Submission
Dependent Change Notification (Addition)
PDF
Entry
Sample
Agent in Charge of HGST Japan, Ltd.
APO_Social Insurance Consultants Corporation
Kagurazaka 1-chome Building
1-15 Kagurazaka, Shinjuku-ku, Tokyo, 162-0825
hgst_shakaihoken_helpdesk@apol.jp
Dependent Certification Record
PDF
Entry
Sample
Dependent Certification Check List
PDF
Entry
Sample
Dependent Change Notification (Removal)
PDF
Entry
Sample
Application for Reissue of Insurance Card
Elderly Recipient Certificate
Eligibility Certificate for Ceiling-Amount
PDF
Entry
Sample
Address Change Notification of the Insured Person
PDF
Entry
Sample
Notification for Acquisition of Qualification as an Insured Person with Optional and Continued Insurance
PDF
Entry
Sample
HGST Health Insurance Association
Yoyogi East 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Application for Purchase of
Exclusive Healthy Menu Option Coupons
PDF
Entry
Sample
Submission for
application forms
1 through 6
Agent in Charge of HGST Japan, Ltd.
APO_Social Insurance Consultants Corporation
Kagurazaka 1-chome Building
1-15 Kagurazaka, Shinjuku-ku, Tokyo, 162-0825
hgst_shakaihoken_
helpdesk@apol.jp
Submission for
application form
7
HGST Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Submission for
application form
8
HGST Health Insurance Association
c/o HGST Japan Human Resource Department
Yoyogi East 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Insured Persons with Optional and Continued Insurance
No. Application Form Document Entry
Sample
Submission
Dependent Change Notification (Optional and Continued Insurance)
PDF
Entry
Sample
HGST Health Insurance Association
Yoyogi East 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Application for Reissue of Insurance Card
Elderly Recipient Certificate
Eligibility Certificate for Ceiling-Amount Application (Optional and Continued Insurance)
PDF
Entry
Sample
Address Change Notification of the Insured Person (Optional and Continued Insurance)
PDF
Entry
Sample
Notification for Loss of Qualification as an Insured Person with Optional and Continued Insurance
PDF
Entry
Sample
Submission for
application forms
9 through 12
HGST Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Standard Application Forms

*Insured persons with optional and continued insurance submit application forms to the HGST Health Insurance Association.

No. Application Form Document Entry
Sample
Submission
Name Change Notification for Insured Person (Dependent)
PDF
Entry
Sample
Agent in Charge of HGST Japan, Ltd.
APO_Social Insurance Consultants Corporation
Kagurazaka-1chome Building
1-15 Kagurazaka, Shinjuku-ku, Tokyo, 162-0825
hgst_shakaihoken_helpdesk@apol.jp
Notification of Long-term Care Insurance Exemption
PDF
Entry
Sample
Notification of Long-term Care Insurance Exclusion
PDF
Entry
Sample
Application for Payment of Medical Care Costs
(Paid in Advance/Therapeutic Devices, etc.)
PDF
Entry
Sample
HGST Health Insurance Association
Yoyogi East 5-23-5 Sendagaya,
Shibuya-ku, Tokyo, 151-0051
Receipt (Medical Examination) Statement
PDF
Application for Payment of Medical Care Costs
(Acupuncture/Moxibustion)
PDF
Entry
Sample
Application for Payment of Medical Care Costs
(Massages)
PDF
Entry
Sample
Application for Health Insurance Payment of Funeral Fees (Expenses) for Insured Person or Family Member
PDF
Entry
Sample
Agent in Charge of HGST Japan, Ltd.
APO_Social Insurance Consultants Corporation
Kagurazaka-1chome Building
1-15 Kagurazaka, Shinjuku-ku, Tokyo, 162-0825
hgst_shakaihoken_helpdesk@apol.jp
Application for Lump-sum Balance of Childbirth/Childcare Allowance
PDF
Entry
Sample
Application for Payment of Childbirth/Childcare Lump-sum Allowance
PDF
Entry
Sample
Application for Payment of the Childbirth/Childcare Lump-sum Allowance
(Substitute Payee System)
PDF
Entry
Sample
Application for Maternity Allowance
PDF
Entry
Sample
Application for Injury and Illness Allowance
PDF
Entry
Sample
Certificate of Consent
PDF
Application for Issuance of Health Insurance Eligibility Certificate for Ceiling-Amount Digital
Application
System
HGST Health Insurance Association
Yoyogi East 5-23-5 Sendagaya,
Shibuya-ku, Tokyo, 151-0051
PDF
Entry
Sample
Health Insurance Application for Issuance of Certificate Issued for Specific Disease Treatment
PDF
Entry
Sample
Point Request for Influenza
Vaccination Subsidy
The 2021 subsidy period has ended
Bank Account Change Notification for Payment Transfers
PDF
Assistance Application for Medical Treatment to Quit Smoking
PDF
Entry
Sample
Submission for
application forms
13 through 15 and
application forms
20 to 26
Agent in Charge of
HGST Japan, Ltd.
APO_Social Insurance Consultants Corporation
Kagurazaka-1chome Building
1-15 Kagurazaka, Shinjuku-ku, Tokyo, 162-0825
hgst_shakaihoken_
helpdesk@apol.jp
Submissionfor
application forms
16 through 19 and
application forms
27 to 31
HGST Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
For more information about the application forms below, please contact the HGST Health Insurance Association (info@hgst-kenpo.jp).
  • Application Forms for Medical Care for Injury or Illness Caused by a Third Party
  • Application for Payment of Transportation Costs
  • Application forms for overseas medical treatment expenses
  • Application for Eligibility Certificate for Ceiling-Amount/Reduction of the Standard Amount of Patient Liability
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