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Application Form & Statement of Physical Condition

Plan:	Medical Plans (with life and disability coverage) MED-A MED-B Short-term - 1 month Short-term - 2 month Short-term - 3 month Short-term - 6 month Life Insurance Plans (without medical) LIFE-A LIFE-B Number of installments Note: 1-3 month Short-term plans require 1 installment payment. 6-month Short-term plan requires 2 installment payments.
Applicant's Information:
Applicant Name:
Gender:	Male Female
Date of Birth (yyyy/mm/dd):
Passport No:
Visa Exp. date:	YYYYMMDD If permanent resident write 'Permanent'
Nationality:
Prefered language:
Applicant's Address in Japan:
Postal Code:
Prefecture:
City:
Address:
Bldg Name & Apt No:
Home Tel:
Mobile Phone:
Employer:
Email:
Email (please confirm):
Beneficiary:
Name:
Relationship:
Date of Birth	YYYYMMDD
Contact Tel (or address):
Effective Date:
On what date would you like your insurance to start? (YYYYMMDD)	Please note, the actual Effective Date and Period may vary, based on when your payment is received and the provisions of this coverage.
Payment Information:
Payment Method:	Convenience Store - We will mail you a payment slip which you can use at ay convenience store.
Statement of Physical Condition: 1) Are you, or any of your dependents who you wish covered on this plan, a policyholder of any life and/or health insurance at the present time?: Yes No 2) Are you taking any medication or receiving any medical treatment at the present time?: Yes No If yes, please explain: 3) Have you ever been hospitalized due to illness or accident?: Yes No If yes, please explain: 4) Have you requested or obtained any benefits from health or life insurance in the past?: Yes No If yes, please explain: 5) Do you have any disability problem at present?: Yes No If yes, please explain: 6) Do you have any medical history of chronic disease listed below?: Yes No If yes, please explain: (1) Benign and malignant tumors. (2) Gastroenterological (stomach, intestine, liver, pancreas, biliary and other) conditions. (3) Cardiovascular (angina pectoris, cardiac infarction, irregular heartbeat, hyperpiesia and other) conditions. (4) Respiratory 8asthma, lung, other) conditions. (5) Neurological/ muscular (brain hemorrhage, cerebral infarction, subarachnoid hemorrhage, cerebral meningitis, epilepsy, myositis, other) conditions. (6) Renal/ urinary (nephritis, nephrosis, prostatauxe, urinary lithiasis, and other) conditions. (7) Metabolic/ Endocrine (diabetes, gout, hyperthyroidism, and other) conditions. (8) Motor(myelitis, arthritis, hip osteoarthritis, and other) conditions. (9) Hematological (leukemia, hyperlipidemia, and other) conditions. (10) Allergic and connective-tissue disorder (Rheumatism, hives, Behcet's Syndrome, and other) conditions. (11) Otorhinolaryngological (Meniere's Disease and other) conditions. (12) Gynecological (Fibroid, ovarian tumor, and other) conditions. (13) Inguinal Hernia (14) Athlete's Foot (15) Ingrown Toenail
Employment: At present, is your occupation listed below? Yes No (1)Professional Athlete (2)Professional Diver (3)Forester (Logger) (4)Professional Hunter (5)Miner (6)Dock Worker (7)Metals Manufacturing Worker (8)Construction Worker (9)Industrial Waste Treatment Worker (10)Electrician Comments:

I hereby apply for membership in the X-pat Plan and certify that all statements and answers provided by me on this "Application Form" and "Statement of Physical Condition" form are complete and true to the best of my knowledge. I also promise to notify underwriters immediately of any changes. I also declare that I have completely read and fully understand the [Summary of Contract] and [Information Calling for Attention] in the above paragraph. I assent that claims may be denied and/or the insurance contract cancelled if the above application contains any false statement or concealment. I also assent that the insurance premium for the cancelled policy is not refundable. A checkmark in the box to the left of this paragraph indicates that I understand and agree to the above.

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