Application Flow
Kamiyacho Clinic

VIVA VIDA ONLINE APPLICATION FORM

Important notice - Please ensure to read -
Before filling in the Application Form please read carefully the [Summary of Contract] and [Information Calling for Attention]. Please take note the escape clauses for non reimbursement.

 

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

Insurance Plan

(1 Year contract)








(Short Plan)









　


※　Click here if you like to apply Foreign Student Insurance.


I Accept the Important Notices

Payment Term

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

Payment Method

Payment Method : *

　　

Applicant's Information

Applicant's Name： *
Sex：*
Birthdate：*
YYYYMMDD
Passport No.：*
Visa Expiry Date：*
YYYYMMDD
Country：*

　Other　

Preferred Language of Documents：*

* Please select which language of documents to be send.

Postal Code：*
Address 1：*
Address 2：*
Phone No.：*
E-mail：*

Insured Person's Information

Relationship with the Applicant:

Copy the Applicant's Information   

I agree with the insurance policy.

　

Insured Person's Name： *
Sex：*
Birthdate：*
YYYYMMDD
Passport No.：*
Visa Expiry Date：*
YYYYMMDD
Country：*

　Other　

Preferred Language of Documents：*

* Please select which language of documents to be send.

Postal Code：*
Address 1：*
Address 2：*
Phone No.：*
E-mail：*

Beneficiary Information

Beneficiary's Name：*
Relationship to the
Insured Person：*
  • Spouse 
  • Child 
  • Parents 
  • Relative 
  • Others
Birthdate：*
YYYYMMDD
Phone 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
Note：

　

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.