VIVA VIDA ONLINE APPLICATION FORM

Select an Insurance Plan*

(One Year Plans)


(Medical & Life Insurance w/ Emergency Plan, for 1 year)

(Medical(30%) & Life Insurance w/ Emergency Plan, for 1 year)

(Life Insurance w/ Emergency Plan, for 1 year)

(Medical & Life Insurance)

(Life Insurance)

(Short Plan)

(Medical & Life Insurance w/ Emergency Plan, for 6 months)

(Medical & Life Insurance w/ Emergency Plan, for 3 months)

(Medical & Life Insurance w/ Emergency Plan, for 2 months)

(Medical & Life Insurance w/ Emergency Plan, for 1 month)

(Medical & Life Insurance Plan for 6 months)

(Medical & Life Insurance Plan for 3 months)

(Medical & Life Insurance Plan for 2 months)

(Medical & Life Insurance Plan for 1 month)

(Medical & Life Insurance w/ Emergency Plan for up to 16 days)

Aggrement to the Document*

Please read 'Summary of Contract and Calling for Attention'* CLICK HERE

I accept.*


Payment Method(One Time Payment Only)
Payment Method*




Payment Term

One time payment is only available*

Please choose a number of payments.*

Please choose a number of payments.*

Applicant's Information

Name*
Name (Furigana)*
Gender*
MaleFemale
Birthdate(YYYY/MM/DD):*
Passport No.*
Visa Expiry Date(YYYY/MM/DD):*
Nationality*
Preferred Language of Documents*

Please enter address and contact number within Japan only. For those with hotel reservation, please enter hotel information including room number; please enter date and duration of stay under NOTES below.

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

Insured Person's Information

Insured person is identical to Contractor.*
Yes No
Relationship with the Applicant*
SpouseChildParentsRelative Others
Name*
Name (Furigana)*
Gender*
MaleFemale
Birthdate(YYYY/MM/DD):*
Passport No.*
Visa Expiry Date(YYYY/MM/DD):*
Nationality*
Preferred Language of Documents*
Postal Code*
Address 1*
Address 2*
Phone No*
E-mail*

Beneficiary Information
Beneficiary's Name*
Relationship to the
Insured Person*
SpouseChildParentsRelative Others
Birthdate(YYYY/MM/DD):*
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.

*
*
*
*
*
*
(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
*
(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.