VIVA VIDA ONLINE APPLICATION FORM

Date of entry to Japan* 
Please apply within 5 days from date of entry to Japan.

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(30%) & Life Insurance w/ Emergency Plan, for 6 months)

(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法人、団体等の場合はどちらかにチェックをお願いします。
Birthdate(YYYY/MM/DD):*
Please select from the calendar displayed.
Passport No.*
日本国籍の方は「NA」と記入してください。日本国籍の方は「NA」と入力してください。
(被保険者となる場合は日本国籍の方でもパスポート番号をご入力ください)
Visa Expiry Date(YYYY/MM/DD):*
Please select from the calendar displayed.
日本国籍の方は「1920/01/01」と入力してください。
Nationality*
Preferred Language of Documents*

Kindly make sure to enter the address information in Japan, the contact number, and the e-mail address information of the applicant or contractor.Moreover,if you plan to stay at a hotel in Japan, please enter the hotel address and the length of stay in the contact information.

Postal Code*
Address 1*
Address 2*
Building name, room number
Phone No*
E-mail*

Insured Person's Information

Insured person is identical to Contractor.*
Yes No
Relationship with the Applicant*
SpouseChildParentsRelativeOthers
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*
*被保険者住所が未定の場合は、契約者住所(連絡先)をご記入ください。
Address 1*
Address 2*
Building name, room number
Phone No*
E-mail*

Life beneficiary information (for in case of death of the insured)
Beneficiary's Name*
Relationship to the Insured Person* SpouseChildParentsRelativeOthers
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.
・In the case of a representative or an agent applies for the insurance other than the insured person, the insured person confirms that he or she understands and agrees to this insurance contract agreement.