Select a Student Insurance Plan*

ST-MED100 : Medical Insurance(100%)+ Life Insurance

  • 1 Month
  • 2 Months
  • 3 Months
  • 6 Months

ST-MED30 EX : Medical Insurance(30%)+ Life Insurance

  • 3 Months
  • 6 Months
  • 9 Months
  • 1 Year

ST-BASIC EX : Life Insurance

  • 3 Months
  • 6 Months
  • 9 Months
  • 1 Year

Aggrement to the Document*

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

I agree to the document above.*


Payment Method
Payment Method*




Payment Term

One time payment is only available*

Applicant's Information
Name*
Name (Furigana)*
Gender*
MaleFemale
Birthdate(YYYY/MM/DD):*
Please select from the calendar displayed.
Passport No.*
Visa Expiry Date(YYYY/MM/DD):*
Please select from the calendar displayed.
Nationality*
Name of school /University in Japan*
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
Visa Type *
Relationship with the Applicant*
SpouseChildParentsRelative Others
Name*
Name (Furigana)*
Gender*
MaleFemale
Birthdate(YYYY/MM/DD):*
Please select from the calendar displayed.
Passport No.*
Visa Expiry Date(YYYY/MM/DD):*
Please select from the calendar displayed.
Nationality*
Preferred Language of Documents*
Postal Code*
Address 1*
Address 2*
Phone No*
E-mail*

Life beneficiary information (for in case of death of the insured)
Beneficiary's Name*
Relationship to the Insured Person* SpouseChildParentsRelative Others
Birthdate(YYYY/MM/DD):* Please select from the calendar displayed.
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.