Online Application Form & Statement of Health Form for X-Pat Insurance

Applicant's Information:
First Name:
Last Name:
Email:
Email (please confirm):
Date of Birth (dd/mm/yyyy):
Age:
Gender:	Male Female
Marital Status:	Married Other
Nationality:
Passport No:
Applicant's Address in Japan:
Postal Code:
Prefecture:
City:
Address:
Bldg Name & Apt No:
Home Tel:
Home Fax:
Mobile Phone:
Employer:
Business Phone:
Contact Person:
Occupation:	Please tell us about your occupation (office worker, construction worker, student, housewife, etc)
Applicant's Address in Home Country:
Street Address:
City:
State/Province:
Country:
Postal Code:
Tel:
Dependents (you wish included in the plan):
Dependent A:
Name:
Relationship:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Premium:
Dependent B:
Name:
Relationship:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Premium:
Dependent C:
Name:
Relationship:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Premium:
Dependent D:
Name:
Relationship:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Premium:
This section is for your beneficiaries: 1st Beneficiary:
Name:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Relationship:
Contact Tel:
Street Address:
City:
State/Province:
Country:
Postal Code:
2nd Beneficiary:
Name:
Date of Birth (dd/mm/yyyy):
Gender:	Male Female
Relationship:
Contact Tel:
Street Address:
City:
State/Province:
Country:
Postal Code:
Effective Date:
On what date would you like your insurance to start? (dd/mm/yyyy):	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:	Bank - Fastest sign-up Convenience Store - Slower sign up (we need to mail you the payment slip)
Plan:
Statement of Health 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, or any of your dependents who you wish covered on this plan, taking any medication or receiving any medical treatment at the present time?: Yes No If yes, please explain: 3) Have you, or any of your dependents who you wish covered on this plan, requested or obtained any benefits from health insurance in the past 3 years?: Yes No If yes, please explain: 4) Have you, or any of your dependents who you wish covered on this plan, suffered any diseases?: Yes No If yes, please explain:

I hereby apply for membership in the X-pat Plan for non-Japanese citizens, underwritten by the Association for the Welfare of Foreign Workers. I hereby certify that all statements and answers provided by me on this "Application Form" and "Statement of Health Condition" form are complete and true to the best of my knowledge. I also acknowledge that if any information given by me is found to be false, benefits payable may be reduced or claims declined. I also promise to notify underwriters immediately of any changes. I also declare that I have completely read and fully understand the Terms of Membership. I authorize any doctor, hospital, clinic, pharmacy, insurance carrier, government agency or other entity having information about my condition of health to release that information to the Association for the Welfare of Foreigner Workers. A checkmark in the box to the left of this paragraph indicates that I understand and agree to the above.

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