VIVA VIDA ONLINE APPLICATION FORM

・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*
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 w/ Emergency Plan for up to 16 days)

Agreement to the Document*

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

I accept.*


Payment Method
Payment Method*




Payment Term

One time payment is only available*

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.

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.

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*
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

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*
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)
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
*
「はい」を選択した場合は、職業を連絡事項欄にご記入ください。
(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

・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.

        


Confirmation of application

Please read carefully and agree to the Terms and Conditions of this insurance.
* CLICK HERE
I agree to the Terms and Conditions