Application for Student Accident Insurance

1.Claim Application Form (Paper Copy)( Please pick up at the Health Center ), or download and print the electronic version from the attachment( The application form has been revised, please use the new version07/2025 version )

2.Original Medical Certificate

3.Original or Copy of Receipt( If it's a copy, it must be stamped by the hospital )

4.Proof of Relationship: Household Registration Transcript(within 3 months ) orNew Household Register - ( Must include detailed entries to prove the parent-child relationship between the parent and the student

5.Copy of Passbook Cover

The attachment provides the above information, a sample application form, and a sample explanation of required documents for parents' reference.

After completing the application form and preparing the documents, please submit them to the Health Center. Thank you.

[Reminder]

★ Please fill out and sign both sides of the paper claim application form.

★ If the attachedaccount information is for thestudent

, please remember to have thestudent personally signat the 'Insured Person', andat the 'Beneficiary'section.

Parent's Signatureat the 'Legal Guardian( Guardian )'section.處

★ If the attachedaccount information is for theparent

, please remember to have thestudent personally signat the 'Insured Person'

and the parent sign at the 'Beneficiary', 'Legal Guardian( Guardian )' section.」