Application Forms

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

Forms Related to Application, a Health Insurance Card and an Eligibility Confirmation Document

No.	Application Form	Document		Sample	Submission Address
	Notification of Change of Dependents (Addition)	PDF	EXCEL	Completed Sample	SATO Labor & Social Security Attorney Office To Salesforce Japan Representative 〒065-8631 8-1-33 Kita 5-jo Higashi, Higashi-ku, Sapporo
	Dependent Status Report Those who submit their individual identification number (“My Number”)	PDF	EXCEL	Completed Sample
	Notification of Individual Number (insured person)※Japanese only	PDF	EXCEL	－
	Individual number report (dependent) ※Japanese only	PDF	EXCEL	－
	Notification of Change of Dependents (Removal)	PDF	EXCEL	Completed Sample
	Application for Reissuance of Health Insurance Card, Eligibility Confirmation Document or Elderly Beneficiary Health Insurance Card Due to Loss/Damage	PDF	EXCEL	Completed Sample
	Application for issuance of Eligibility Confirmation Document	PDF	－	－
	Application form for canceling registration of the use of Individual Number Card as a Health Insurance card	PDF	－	－
	Name Change Notice※Japanese only	PDF	EXCEL	Completed Sample
	Application for Issuance of Eligibility Certificate for Ceiling-Amount Application※Japanese only for documents	Online Application			Salesforce Health Association 〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo
		PDF	EXCEL	Completed Sample
	Application for Issuance of Certificate of Medical Treatment for Specified Diseases ※Japanese only	PDF	EXCEL	Completed Sample
	Application Regarding Listing of Gender for Insured Person, Etc.	PDF	EXCEL	Completed Sample
	Application Regarding Listing of Common Name on Health Insurance Card, Etc.	PDF	EXCEL	Completed Sample
	Notification for Acquisition of Eligibility as an Insured Person with Optional and Continued Insurance	PDF	EXCEL	Completed Sample
	Application for Forfeiture of Status as an Insured Person with Optional Continued Insurance※Japanese only	PDF	EXCEL	Completed Sample
	Application for Certification of Date of Status Acquisition or Loss※Japanese only	PDF	EXCEL	–

Submission Address
for application forms 1 through 9

SATO Labor & Social Security Attorney Office To Salesforce Japan Representative
〒065-8631 8-1-33 Kita 5-jo Higashi, Higashi-ku, Sapporo

Submission Address
for application forms 10 through 16

Salesforce Health Association
〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo

Benefits Related

No.	Application Form	Document		Sample	Submission Address
	Application for Injury and Illness Allowance	PDF	EXCEL	Completed Sample	SATO Labor & Social Security Attorney Office To Salesforce Japan Representative 〒065-8631 8-1-33 Kita 5-jo Higashi, Higashi-ku, Sapporo
	Information Disclosure Consent Form	PDF	WORD	–
	Response Form for Previously Affiliated Health Insurance Enrollment Status	PDF	EXCEL	Completed Sample
	Application for Childbirth Allowance	PDF	EXCEL	Completed Sample
	Application for Payment of Burial Fees (Expenses) and Additional Benefits ※Japanese only	PDF	EXCEL	Completed Sample
	Application for the Childbirth and Childcare Lump-sum Allowance and Additional Benefits (No Use of the Direct Payment System)	PDF	EXCEL	Completed Sample	Salesforce Health Association 〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo
	Application for Payment of the Childbirth and Childcare Lump-sum Allowance (Substitute Payee System)	PDF	EXCEL	Completed Sample
	Application for Payment of Medical Care Costs (Advance Payment)	PDF	EXCEL	Completed Sample
	Application for Payment of Medical Care Costs (For Therapeutic Devices, Therapeutic Eyeglasses, etc.) ※Japanese only	PDF	EXCEL	Completed Sample
	Documents to be attached to the application for payment of medical care costs for therapeutic devices (therapeutic device manufacturing confirmation form) ※Japanese only	PDF	EXCEL	–
	Application for Payment of Medical Care Costs (for Acupuncture and Moxibustion) ※Japanese only	PDF	EXCEL	Completed Sample
	Application for Payment of Medical Care Costs (Massages)※Japanese only	PDF	EXCEL	Completed Sample
	Application for Payment of Medical Care Costs (Overseas Medical Expenses) ※Japanese only	PDF	EXCEL	Completed Sample
	Attending Physician's Statement (Form A) (Overseas)	PDF	EXCEL	–
	Itemized Receipt (Form B) (Overseas)	PDF	EXCEL	–
	Attending Physician's Statement (Dental) (Overseas)	PDF	EXCEL	–
	Investigation Authorization Agreement for Overseas Medical Care Costs (Overseas)	PDF	EXCEL	–

Submission Address
for application forms 17 through 21

SATO Labor & Social Security Attorney Office To Salesforce Japan Representative
〒065-8631 8-1-33 Kita 5-jo Higashi, Higashi-ku, Sapporo

Submission Address
for application forms 22 through 33

Salesforce Health Association
〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo

Healthcare Related

No.	Application Form	Document		Sample	Submission Address
	Medical checkup in 2024	Please check this list of medical institutions (affiliated clinics) that are eligible for regular health checkups. * From FY25, if you receive treatment at a medical institution that is not on the list above, you will not receive company/health insurance subsidies.
	Dental examination expense settlement form※Japanese only for documents	Online Application			Salesforce Health Association 〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo
		PDF	EXCEL	－
	Application for Subsidy of Influenza Vaccination Cost ※Japanese only for documents	Online Application
		PDF	EXCEL	Completed Sample

Submission Address
for application forms 35 through 36

Salesforce Health Association
〒100-0005 Nihon seimei marunouchi garden tower（Salesforce Tower）,1Chome 1-3 Marunouchi, Chiyoda-ku, Tokyo

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