We will accept applications until 5:00 p.m. (Japan Standard Time) on January 31, 2025 (Friday). However, please note that we will not be able to accept applications for policies with an inception date on or after February 1, 2025.
※Please note that if, after application, the policy contract is not concluded by February 13th due to any reason such as your delay in response to our inquiries or in payment of premiums, the application will be deemed invalid.

・Applications from outside Japan are not accepted. Please apply after entering Japan.
・Please apply in person.
We cannot handle insurance where the insured is different from the policyholder.
However, if a parent (or guardian) applies for an insurance contract with a minor child as the insured person, you can apply according to the form below.

Date of entry to Japan*

Select an Insurance Plan*

(One Year Plans)

Agreement to the Document*

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

I understand and agree to the contents of the Important Information Statement.*

Payment Method
Payment must be made by the subscriber yourself

Payment Method*

Convenience Store(Payment form will be mailed to you)
Bank(1 Time Payment Only)
Credit Card (1 Time Payment Only)

Payment Term

One time payment is only available*

1 time

Please choose a number of payments.* The total premium payment will be higher if paid in installments. For details, please refer to the price list of each insurance plan.	1 time
	2 times

Please choose a number of payments.* The total premium payment will be higher if paid in installments. For details, please refer to the price list of each insurance plan.	1 time
	2 times
	3 times
	4 times
	5 times
	6 times

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. 日本国籍の方は「1920/01/01」と入力してください。
Nationality*
Please fill in if 'Others' is selected
Preferred Language of Documents*

Please enter your address in Japan or the address of the hotel where you plan to stay, as well as a telephone number and e-mail address where we can contact you. If you plan to stay at a hotel, please enter the length of your stay in the contact information.

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

Insured Person's Information

We cannot handle insurance where the insured is different from the policyholder.
However, if a parent (or other guardian) is applying for an insurance contract with their minor child as the insured party, please select [No] and provide information about the insured child (minor only).
Please fill in the required information.
In addition, in the special notes section, please write,
As the insured's legal guardian, I certify that the insured has agreed to become the insured of this insurance,
and that the information disclosed regarding the insured is genuine.

Insured person is identical to Contractor.*

Yes No

Relationship with the Applicant*	SpouseChildParentsRelativeOthers
	In the event that you select an option other than "child", we will contact you.

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*
Please fill in if 'Others' is selected
Preferred Language of Documents*
Postal Code*	If the insured person’s address is not yet determined, please enter the policyholder's address (contact information).
Address 1*
Address 2*
Building name, room number
Phone No*
E-mail*

Life beneficiary information (for in case of death of the insured)　As a general rule, please designate a relative within the second degree of kinship.

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.

・The earliest insurance start date is the day after the premium payment is received.
If you wish to start insurance on a date other than the above, please also enter the reason below.

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.
・After confirming that the contents of the insurance coverage, insurance period, payment period, premiums, and premium payment method are in line with your intentions, you apply for the insurance policy.

The insured person's age is out of the scope of insurance!

VIVA VIDA ONLINE APPLICATION FORM

Confirmation of application