MIRAI LIFE. We care | First Insurance plan dedicated for expats living in japan to cover both medical and life in single plan (Mirailife Insurance)

Preferred Plan for Insured Person

Select Plan

DOB ^*

Age(auto calculated)

Payment Term ^*

Insurance Fee
(Based on chosen plan)

Benefits	Mirai Basic	Mirai Premium
Hospitalization Benefit (per day)	¥5,000/Day	¥10,000/Day
Surgery Benefits (fixed)	¥30,000	¥60,000
Post Care/Discharge Benefits (fixed)	¥10,000	¥20,000
Death or Severe Disability due to Illness (fixed)	¥1,000,000	¥1,000,000
Death or Severe Disability due to Injury (fixed)	¥2,000,000	¥2,000,000

^* I want to get add-on benefits on death or severe disability apart from medical benefits (hospitalization, surgery and post-care) within a plan. I have choosen the appropriate insurance plan after reading contract terms and plan benefits while processing this application.

About Notice !

You may not be able to receive benefits/insurance benefits if the notification is different from the fact or if the fact is not announced. In addition, the insurance contract may be terminated.
If choose "Yes" in any of the notification items:
- The notified illness etc. is not covered by the guarantee, but if there is no recurrence or related symptoms within 5 years after the doctor has reported a complete cure, it is covered by the guarantee. (Illnesses that have a strong relationship with the announced illness, etc., and illnesses and body parts that are difficult to suffer from the same illness group in the "Specific illness group" listed in the important matters manual are also treated in the same way.)
- Depending on your health or physical condition, the choice of Insurance plan may be limited, "special conditions" that some diseases may not be covered, or you may not get confirmation of application.

Illness or injury that does not require notification:

Hay fever (Allergic rhinitis), atopic dermatitis, acne, athlete's foot, tooth decay, orthodontics, cold that has been completely cured within 7 days.
Influenza, childbirth due to normal delivery, mild limbs completely cured at the time of application Injury (cuts, abrasions, burns, fingers, bruise, sprains)

Please be sure to check when filling out the health condition notification form:

Q1 : Do you currently have any chronic illnesses or illnesses for which treatment is pending?
※ It does not matter whether you receive medical treatment at a medical institution or whether you have medical treatment.
No Yes
Q2 : Do you currently have any physical or mood symptoms/abnormalities such as fever, pain, coughing, or feeling irritated?
※ Those who have not been examined at a medical institution.
No Yes
Q3 : Have you ever seen a medical institution within the past 3 months and received a medical examination/test/treatment (medicine)?
※ Not limited to illness or injury requiring hospitalization or surgery.
No Yes
Q4 : Have you received more than 5 treatments (medications) for the same illness or injury within the past 3 years?
※ Not limited to illness or injury requiring hospitalization or surgery.
No Yes
Q5 : Have you been hospitalized or had surgery for illness or injury within the last 5 years?
No Yes
Q6 : Have you ever noticed any abnormality in your health checkup or medical checkup within the past two years?
※ Are there any follow-up observations, re-examination required, detailed examination required, treatment required, etc.?
No Yes
Q7 : Are you currently having a physical or functional disability?
※ Disability of visual acuity, hearing, language, masticatory function, hand/foot/finger defect or function impairment, joint/spine/spine deformity, etc.
No Yes
Q8 : Are you pregnant now ?
※ Applicable only for Female.
No Yes

We will send separate form by Post in your registered address where you need to write the details about your medical record and return to us. Based on that we will review and send the confirmation if your application for Insurnace shall be accepted or not.

Applicant Information

Applicant Type

Email ^*
(email will be sent here)

Email already used. If you've already applied using this email before, you can instead login from here and directly add insured person.

First Name ^*

Last Name ^*

Full Name in Furigana

Company Name/Work

Occupation

Nationality ^*

Passport Number

Gender/Sex ^*

M F O

DOB

Age(auto calculated)

Company Name ^*

Name of Company Representative

Country of Residence ^*

Postal Code

Province ^*

City ^*

Street Address

Building Name

Mobile No. ^*

Other Contact

KYC Type ^*

Applicant KYC Front ^*

(Max Size: 2MB ; Format:jpg/png/pdf)

Applicant KYC Back ^*

(Max Size: 2MB ; Format:jpg/png/pdf)

Insured Person Information

Relationship with Insured Person

First Name ^*

Last Name ^*

Full Name in Furigana

Company Name/Work

Occupation ^*

Nationaltiy ^*

Passport Number

Gender/Sex ^*

Male Female Other

DOB

Age(auto calculated)

Country of Residence ^*

Postal Code

Province ^*

City ^*

Street Address

Building Name

Mobile No. ^*

Other Contact No.

KYC Document Type ^*

Front Side ^*

(Max Size: 2MB ; Format Support: jpg/png/pdf)

Back Side ^*

(Max Size: 2MB ; Format:jpg/png/pdf)

Country Of Origin ^*

District/City ^*

Beneficiary Information of Insured Person in Case of Death Benefit

Beneficiary's Name ^*

Relationship to Insured Person

Address Same as Insured Person?

Country of Residence

Postal Code

Province/State

City/District

Street Address

Building Name

Phone No.

About Parent/Guardian Consent

^* 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 plans for the cancelled policy is not refundable.

Note: Most fill Parent/guardian Information if Age of the Insured Person is 19 or less then 19. This is required as per low due to applicant or insured person with age of 19 or less is not responsible for civil law.

Parent/Guardian Name ^*

Relationship with Insured Person ^*

Registration & Payment Information

Referer/Agent ^*

Application Date

Plan Enroll Date ^*

Payment method ^*

^* 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 undertand the contents and important explainations (contract outline, insurance period, caution informations and regulations regarding personal information protection) and apply my prefered Insurance plan contract for Insured Person and I accept it. 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 plans for the cancelled policy is not refundable.