Online Application

In case you designate the inception date of the insurance or you wish to add second beneficiary, please input information on the Notes below.

Contract Information

Insurance Plan

  •  VIVAMED-A    
    •  VIVALIFE-A    
    •  SHORT TERM 1month     
    •  SHORT TERM 2months
    •  SHORT TERM 3months    
    •  SHORT TERM 6months

Number of Payment

* Short term plan 1-3months one time payment only. 6months 2 installments.


Applicant's Information

Applicant's Name

Gender

Date of Birth

YYYYMMDD

Passport Number

Visa Expiration

YYYYMMDD
Please input eight-digit 9 numbers for the permanent visa.

Nationality

 Others 

Preferred Language of Documents


* Please select which language of documents to be send.

Postal Code

Address 1

(Prefecture, City, District)

Address 2

(Number)

Address 3


(Building name, Apartment number)

Telephone no.

E-mail address

Confirmation of
E-mail address



Insured Person's Information

Relationship with the Applicant


* Please select which language of documents to be send.

Copy the Applicant's Information


Insured Person's Name

Gender

Date of Birth

YYYYMMDD

Passport Number

Visa Expiration

Nationality

 Others 

Preferred Language of Documents


* Please select which language of documents to be send.

Postal Code

ex. 000-0000

Address 1

(Prefecture, City, District)

Address 2

(Number)

Address 3


(Building name, Apartment number)

Telephone no.

E-mail Address

Confirmation of
E-mail Address



Beneficiary's Information

Beneficiary's Name

Relationship to the Insured Person

  •  Spouse   
  •  Child   
  •  Parents   
  •  Relative   
  •  Others

Date of Birth

YYYYMMDD

Telephone no.


Information of member's physical condition. Please ensure to fill in the necessary details by the insured person.
Please answer the follwing questions yes or no.

Are you a policyholder of any life and/or health insurance at the present time other than VIVA VIDA!?

  •  Yes   
  •  No

Are you taking any medical treatment at the present time?

  •  Yes   
  •  No

Have you been hospitalized due to illness or accident in the past?

  •  Yes   
  •  No

Have you requested or obtained any benefits from life insurance in the past?

  •  Yes   
  •  No

Do you have any disability problem at present?

  •  Yes   
  •  No

Do you have any medical history of chronic disease listed below?

  •  Yes   
  •  No

(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 (asthma, 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

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
Notes

I hereby certify that all statements and answers provided by me in this section are complete and true to the best of my knowledge. I assent that the claims will be denied and/or the insurance contract will be cancelled if the statements above contain false or injustice. I also assent that the insurance premium for the cancelled policy is not refundable.
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