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How to fill in the shikaku soshitsu todoke(Japan's loss of insured status notification, free template)

The shikaku soshitsu todoke is the notification an employer files when an employee stops being covered by Japan's social and employment insurance, usually because they leave the company. Enter the last day to get the date coverage ends and the filing deadlines, then download the filing sheet as PDF, Word or Excel (forms as of October 2026).

Create it free See the sample
  • Dates and deadlines5 and 10 days
  • Social and employment insurance2 forms
  • English and Japanese2 languages
By Emmanuel Gendre Updated
Documents this template makes: the filing sheet for the loss of insured status notification (social insurance), the Japanese version and the notice for the employee

Loss of insured status notification template (filing sheet and notice)

The documents on the right update as you type. Switch between social insurance (health insurance and employees' pension) and employment insurance; the date coverage ends and the deadlines are worked out from the last day.

Five steps

Step 1 Workplace

Enter the company filing the notification. Use the switch above to choose the social insurance or the employment insurance form.

Workplace

Health insurance and employees' pension

With a health insurance society, you file with both the Japan Pension Service and the society.

Step 2 Leaving employee

Enter the details of the employee who stops being insured.

Leaving employee

The number the Japan Pension Service assigned when the employee joined.

Do not enter the My Number (Individual Number) here. After checking the employee's identity, write it directly on the form.

Step 3 Last day

The date coverage ends and the deadlines are worked out from the last day.

Dates

Date coverage ends: November 1, 2026 (9-081101). Filing deadline: November 5, 2026 (within 5 days of the date coverage ends).

Reason for loss

Step 4 Attachments

Set the documents to attach and the remarks box.

Eligibility certificates and remarks

pcs
pcs

Leave 0 for an employee who uses the My Number health card and has no eligibility certificate. If any cannot be returned, also file a non-return notification.

Step 5 Notice and English

Add a notice for the leaving employee, and the English wording of the documents.

Notice for the employee

Preview

Loss of Coverage Notification: Filing Sheet

Health Insurance and Employees' Pension: Notification of Loss of Insured Status (Japan Pension Service form)

This sheet records what goes on the Japan Pension Service form. The notification itself is filed on the official form (PDF or Excel) or online; this sheet is the company's copy and an English reference.

Filer

Submission dateNovember 2, 2026
Office reference symbol / number01-アイウ　12345
Office address1-2-3 Uchikanda, Chiyoda-ku, Tokyo 101-0047
Office nameMinato Shoji Co., Ltd.
EmployerTaro Yamada, Representative Director
Phone03-1234-5678

Insured person

(1) Reference number25
(2) NameHanako Sato
(3) Date of birth7-020514 (May 14, 1990)
(4) Individual Number (basic pension number)Write the 12-digit My Number directly on the form
(5) Date of loss of coverage9-081101 (November 1, 2026)
(6) Reason for loss4. Retirement etc. (left on October 31, 2026)
(7) RemarksNone
Eligibility certificates returnedAttached: 0 / Cannot be returned: 0
(8) No longer a 70+ employeeNot applicable

Where, when and what to attach

Submit toJapan Pension Service operations center (online or by post) or the local pension office (in person)
DeadlineNovember 5, 2026 (within 5 days of the date coverage ends)
AttachmentsNone (no eligibility certificate was issued)

October 31, 2026

To: Hanako Sato

Notice of Loss of Insurance Coverage

As you are leaving the Company on October 31, 2026, your health insurance, employees' pension and employment insurance coverage ends as set out below. Please check the procedures you need to complete after you leave.

  1. Date coverage endsYour health insurance and employees' pension coverage ends on November 1, 2026 (the day after your last day). From that day you can no longer use the Company's health insurance.
  2. Items to returnPlease return your eligibility certificate (shikaku kakuninsho), and those of your dependants, if issued, by your last day. You keep your My Number health card.
  3. Health insurance after you leavePlease join one of the following.
    • Your new employer's health insurance
    • National Health Insurance at your city office (within 14 days of the date coverage ends)
    • Voluntary continuation (nin'i keizoku) with the Japan Health Insurance Association (apply within 20 days; up to 2 years)
    • A family member's health insurance, as a dependant
  4. PensionIf you do not start a new job right away, switch to the National Pension at your city office within 14 days of the date coverage ends.
  5. Employment insuranceWe will send you your separation notice (rishokuhyo) as soon as Hello Work issues it. You apply for unemployment benefits at the Hello Work office for your address.
  6. Withholding tax slipWe will give you your withholding tax slip (gensen choshuhyo) within one month after you leave.
  7. ContactSuzuki, HR Department (03-1234-5678)

End

Minato Shoji Co., Ltd.

Taro Yamada, Representative Director

The filing sheet and the notice take one page each. In the PDF, the notice follows the filing sheet.

The PDF, Word, Excel and sample downloads need your email address. What you type stays in your browser, and the PDF is made on your device. The notification itself is filed on the official form of the Japan Pension Service or Hello Work.

Basics

What is the shikaku soshitsu todoke? Two forms: social and employment insurance

The shikaku soshitsu todoke (loss of insured status notification) is what a company files when an employee stops being covered by social or employment insurance, for example on leaving or death. The health and pension insurance notification goes to the Japan Pension Service (operations center or pension office) within 5 days; the employment insurance notification goes to Hello Work within 10 days.

Two different notifications go by this name: the health and pension insurance notification, which covers health insurance and employees' pension together (Japan Pension Service), and the employment insurance notification (Hello Work). If the employee was in both schemes, you file both. The employer prepares and files each of them; the employee does not.

Health and pension insurance vs employment insurance: the two notifications

Health and pension insurance vs employment insurance: the two notifications
ItemHealth and pension insuranceEmployment insurance
NameHealth and Pension Insurance Notification of Loss of Insured Status / Notification of No Longer Being a 70+ EmployeeEmployment Insurance Notification of Loss of Insured Status (Form No. 4)
File withThe operations center or the local pension office (and the health insurance society, if the company is in one)The Hello Work office for the workplace
DeadlineWithin 5 days of the event (5 days from the day after the last day)Within 10 days from the day after the person stopped being insured
Coverage endsThe day after the last day (the form takes the date coverage ends)The day after the separation date (the form takes the separation date)
Main attachmentsEligibility certificates (Kyokai Kenpo, if issued)Documents showing the reason and the last day; the separation certificate (when a separation notice is wanted)
How to fileOnline, by post or in personOnline, by post or in person (online for specified corporations)
Legal basisHealth Insurance Act Art. 48; Employees' Pension Insurance Act Art. 27Employment Insurance Act Art. 7; its Enforcement Regulations Art. 7

Sources: Japan Pension Service, “When an employee leaves or dies (loss of health and pension insurance)”; e-Gov, Employment Insurance Act Enforcement Regulations, Article 7.

The template previews in English by default; switch it to “Japanese” to get the same sheet in Japanese, the language of the official forms. The English version helps when you explain the procedure to a foreign employee or to a head office abroad. The notification itself is always filed on the Japanese form.

Documents

What to attach and what to collect

Each notification has its own attachments: the collected eligibility certificates for health and pension insurance, and documents showing why and when the employee left for employment insurance.

What to attach to the notification and what to collect
DocumentNotificationDetails
Eligibility certificatesHealth and pension insurance (Kyokai Kenpo)Collect and attach any eligibility certificates and elderly recipient certificates issued to the employee and their dependants. With a health insurance society, nothing is attached to the Japan Pension Service notification.
Non-return
notification		Health and pension insurance (Kyokai Kenpo)Filed when an eligibility certificate cannot be collected.
Proof of reason
and last day		Employment insuranceFor example a copy of the resignation letter, the advance notice of dismissal or the employment contract, plus attendance records or time cards.
Separation certificateEmployment insuranceAttached when the employee wants a separation notice, and always when they are 59 or older on the separation date (Employment Insurance Act Enforcement Regulations, Art. 7(3)).
Wage ledger and attendance recordsEmployment insurance (with a separation certificate)Given to Hello Work as proof of the wages and days written on the separation certificate.
Residence card detailsEmployment insurance (foreign nationals)Written in boxes 14 to 19, they also serve as the report on the employment of foreign nationals (separation).

Sources: Japan Pension Service, “When an employee leaves or dies (loss of health and pension insurance)”; Hello Work Asahikawa, list of documents to file; Hello Work Internet Service, notes on the employment insurance notification.

New health insurance cards stopped being issued on December 2, 2024, and the remaining ones expired by December 1, 2025. What you collect today is the eligibility certificate (shikaku kakuninsho) issued to people who do not use the My Number health card. The My Number card belongs to the employee and is not collected.

Who fills in the notification?

The employer prepares and files it; the employee does not. A labor and social security attorney (sharoshi) can file it for you, in which case they fill in the attorney box on the form.

What to tell the leaving employee

From the date coverage ends, the former employee can no longer use the company health insurance. Someone not starting a new job right away enrols in National Health Insurance and the National Pension within 14 days of that date, or applies for voluntary continuation within 20 days. The template's loss of coverage notice gives the date and these deadlines, so handing it over on the last day saves questions later. For the full list, see what to tell a leaving employee in our separation guide.

Deadlines

Filing deadlines and the date coverage ends

File the health and pension insurance notification within 5 days from the day after the last day, and the employment insurance notification within 10 days from the day after the person stopped being insured. A notification is needed in each of these cases:

  • Leaving (resignation, dismissal, end of contract, retirement age and so on)
  • The employee's death
  • Becoming a director (employment insurance, when the person is no longer treated as insured)
  • Scheduled hours dropping below 20 a week (employment insurance)
  • A secondment where the receiving company insures the employee, or the return from one
  • Turning 75 and moving to the medical care system for people aged 75 and over (health insurance only)

How the date coverage ends is set

Date health and pension coverage ends
ReasonCoverage ends on
LeavingThe day after the last day
Transfer, contract changeThe day of the transfer to another registered workplace, or of the contract change that ends coverage
DeathThe day after the date of death
Turning 75 (health only)The birthday itself
Disability certification (health only)The day of certification
Social security agreementThe day the agreement takes effect, or the day after the other country's law starts to apply

Source: Japan Pension Service, sample of the health and pension insurance loss of insured status notification. The employment insurance notification takes the separation date (the last day on the books), not the date coverage ends.

For example, for an employee leaving on October 31, health and pension coverage ends on November 1; file that notification by November 5 and the employment insurance one by November 11. Social insurance premiums are due up to the month before the month in which coverage ends (Health Insurance Act Art. 156(3), Employees' Pension Insurance Act Art. 19(1)). Leaving at the end of a month moves the end of coverage to the 1st of the next month, so that month's premium is due; leaving mid-month means no premium for that month.

Filing takes five steps:

  1. Confirm the last day of employment and the date coverage ends

    Check the last day of employment against the resignation letter or the advance notice of dismissal, then set the date health and pension coverage ends (the day after the last day) and the deadlines for both notifications.

  2. Collect the eligibility certificates

    By the last day, collect the eligibility certificates of the employee and their dependants, if any were issued. If one cannot be collected, prepare a non-return notification for it.

  3. File the health and pension insurance notification within 5 days

    Fill in the Japan Pension Service form and file it online, by post to the operations center, or in person at the pension office. Companies in a health insurance society also file with the society.

  4. File the employment insurance notification and separation certificate within 10 days

    File it with the Hello Work office for your workplace, with documents showing the reason for leaving and the last day. Attach the separation certificate when the employee wants a separation notice (rishokuhyo), and always when they are 59 or older on the separation date.

  5. Receive the confirmation and hand the documents to the employee

    Once a notification is accepted, you receive a confirmation of loss of insured status. Hand the separation notice issued by Hello Work and the employee's copy of the employment insurance confirmation to the former employee promptly.

How to fill it in

How to fill in the notification: fields and sample

The health and pension insurance notification has a filer section and boxes (1) to (8) for each insured person; one sheet covers up to 4 people. The right-hand column shows how this template's filing sheet handles each box.

Fields of the health and pension insurance loss of insured status notification
BoxWhat to writeThis templateFiling sheet
Filer sectionFiling date, office reference symbol and number, workplace address and name, employer's name, phoneStep 1
(1) Reference
number		The number assigned when the employee joinedAs entered
(2) NameName and katakana readingAs entered
(3) Date of birthEra code (5 Showa, 7 Heisei, 9 Reiwa) and the dateConverted
(4) Individual
Number		My Number; the basic pension number for a loss by deathOn the form
(5) Date coverage endsThe day after the last day; era code 9 (Reiwa)Calculated
(6) Reason
for loss		4 retirement etc., 5 death, 7 turning 75, 9 disability certification, 11 social security agreement, 12 voluntary loss under the special reduction rule; for leaving or death, also write the dateChoice
(7) Remarks,
certificates		1 loss at one of two or more workplaces, 2 loss on re-employment right after retirement, 3 other; the number of eligibility certificates attached and not returnedChoice, count
(8) No longer 70+When an employee aged 70 or over leaves or dies: the date (last day or date of death)Switch

Source: Japan Pension Service, sample of the health and pension insurance loss of insured status notification. An employee who turns 70 while working is reported on the age-70 notification instead.

Fields of the employment insurance notification

The employment insurance notification (Form No. 4) is read by machine (OCR), so write inside each box without crossing its edges. The main boxes:

Fields of the employment insurance loss of insured status notification
BoxWhat to write
Box 1
Individual Number		My Number (handwritten after printing)
Box 2
Insured number		The number on the employment insurance card or the confirmation of enrolment
Box 3
Office number		The workplace's employment insurance number
Box 4
Start date		Era code (3 Showa, 4 Heisei, 5 Reiwa) and the date
Box 5
Separation date		The last day on the books (the last day of employment); the date of death on death
Box 6
Reason code		1 not a separation (death, secondment, return from secondment); 2 separation other than 3, meaning any separation not for the employer's reasons (resignation, end of contract, retirement age with a re-employment scheme, transfer secondment, dismissal for serious misconduct and so on); 3 separation for the employer's reasons (dismissal, encouraged resignation, retirement age under 65 without a re-employment scheme and so on)
Box 7
Separation notice		1 (yes) if the employee wants a separation notice, 2 (no) if not
Box 8
Weekly hours		Scheduled weekly hours on the separation date (hours and minutes)
Box 9
Replacement		1 (yes) if you plan to hire a replacement
Boxes 14 to 19
Foreign nationals		Foreign nationals only (not special permanent residents or the “diplomat” and “official” statuses): name in Roman letters, residence card number, period of stay, dispatch or contract work, nationality or region, status of residence
Boxes 20 to 25
Name, address		Name, sex, date of birth, address, workplace name, date of any name change
Box 26
Cause		Why the person stopped being insured: the reason for leaving, as specifically as you can

Source: Hello Work Internet Service, notes on the employment insurance notification. Boxes 11 to 13 are filled in by Hello Work.

How to word the cause of loss (box 26), with examples

The cause in box 26 affects whether the former employee gets the basic allowance (unemployment benefit) and for how many days. Write it as specifically as you can, consistent with the attachments such as the resignation letter. Hello Work's own sample reads “the employee asked to leave to change jobs”. Common wording, with the box 6 reason code (the form is filled in Japanese; the template writes both languages):

  • Resignation: “The employee asked to leave in order to change jobs.” (2)
  • End of contract: “The fixed-term contract ended and was not renewed.” (2)
  • Retirement age: “The employee reached retirement age and did not ask to be re-employed.” (2)
  • Becoming a director: “The employee became a director and is no longer treated as insured.” (2)
  • Fewer hours: “Scheduled weekly hours fell below 20.” (2)
  • Dismissal: “The employee was dismissed in a workforce reduction due to downsizing.” (3)
  • Encouraged resignation: “The employee left after accepting the company's request to resign.” (3)

If the company and the former employee disagree, Hello Work checks the facts and decides the reason for leaving. Choosing the box 6 reason in the template puts this wording in box 26.

The official forms (Japan Pension Service, Hello Work)

The Japan Pension Service and Hello Work publish the forms for free. The notification must be made on the prescribed form, so file on the official form or online (the forms are set by Ministry of Health, Labour and Welfare ordinance). This page's filing sheet sets out what goes on the form and gives you a copy for your records.

Health and pension insurance

The Japan Pension Service form, published as PDF and Excel; one sheet covers up to 4 people. The Excel version can print out of alignment, so check the margins and layout before printing.

Japan Pension Service form: health and pension insurance notification of loss of insured status (blank)
Source: Japan Pension Service, notification of loss of insured status. Download the form (PDF, Excel) and sample

Employment insurance

Hello Work Form No. 4. Print it blank or type the details in first. Print on plain white A4 paper at 100% and check that the three black squares used for scanning are not faint.

Hello Work Form No. 4, employment insurance notification of loss of insured status, page 1 (blank)
Source: Hello Work Internet Service, employment insurance notification of loss of insured status. Print the form (Hello Work Internet Service)

Sample, Word and Excel versions

A sample made with the template above (health and pension insurance, employee leaving on October 31). The sample PDF and the Word and Excel templates download after you enter your email. In the Word version, replace the [ ] parts to make the filing sheet and the notice; in the Excel version, enter the last day on the input sheet and the date coverage ends and the deadlines are calculated.

Sample filing sheet for the loss of insured status notification (health insurance and employees' pension; left on October 31, coverage ends November 1, no eligibility certificate returned)
Page 1 of the filing sheet: the filer section, boxes (1) to (8), where and when to file, and the attachments.

Legal basis

Legal background and limits

The notification is a legal duty of the employer. Here is what happens when it is late, and what changes with the company's size, its health insurer, and the employee's age or nationality.

The duty to file, and penalties

The health and pension insurance notification is required by Article 48 of the Health Insurance Act and Article 27 of the Employees' Pension Insurance Act; the employment insurance notification by Article 7 of the Employment Insurance Act. The forms are set by the Health Insurance Act Enforcement Regulations (Form No. 8) and the Employment Insurance Act Enforcement Regulations (Form No. 4). Failing to file without good reason, or filing false information, is punishable by up to 6 months' imprisonment or a fine of up to 500,000 yen (Health Insurance Act Art. 208, Employees' Pension Insurance Act Art. 102), and by up to 6 months' imprisonment or a fine of up to 300,000 yen (Employment Insurance Act Art. 83). If you miss a deadline, file as soon as you notice.

Some companies must file the employment insurance notification online

Corporations with capital or contributions over 100 million yen, mutual companies, investment corporations and special purpose companies (“specified corporations”) must file the employment insurance notification online for business years starting on or after April 1, 2020. For health and pension insurance, the online duty covers the annual remuneration report, the monthly change report and the bonus report; the loss of insured status notification can be filed online, by post or in person.

Health insurance societies, two workplaces, age 70+

A company in a health insurance society files with the Japan Pension Service and the society at the same time. When someone working at two or more workplaces leaves one of them, choose remark 1 in box (7), “loss at one of two or more workplaces”. When someone aged 60 or over is re-employed with no gap after retiring, choose remark 2, “loss on re-employment right after retirement”, and file it together with the enrolment notification. When an employee aged 70 or over leaves (no longer in employees' pension, so reported as a “70+ employee”), fill in box (8), “no longer a 70+ employee”.

When a foreign employee leaves

When a foreign employee covered by employment insurance leaves (special permanent residents and the “diplomat” and “official” statuses excepted), writing the residence card details in boxes 14 to 19 also serves as the report on the employment of foreign nationals. For a foreign employee not covered by employment insurance, file that report with Hello Work by the end of the month after the month they left.

FAQ

Shikaku soshitsu todoke: frequently asked questions

Who fills in and files the loss of insured status notification?

The employer fills it in and files it; the employee does not. The health and pension insurance notification goes to the Japan Pension Service (operations center or pension office) and the employment insurance notification to Hello Work. You can also have a labor and social security attorney (sharoshi) file it for you.

What is the filing deadline, and what happens if you are late?

Health and pension insurance: within 5 days of the event (for a departure, within 5 days from the day after the last day). Employment insurance: within 10 days from the day after the person stopped being insured. Filing late also delays the former employee's National Health Insurance enrolment and unemployment benefit claim. Failing to file without good reason is punishable (up to 6 months' imprisonment or a fine of up to 500,000 yen under Article 208 of the Health Insurance Act and similar provisions), so file as soon as you notice.

When does pension (social insurance) coverage end?

On the day after the last day of employment. If an employee leaves on October 31, coverage ends on November 1. On death, it ends on the day after the date of death. Premiums are due up to the month before the month in which coverage ends, so an employee who leaves at the end of a month also pays for that month.

What is the date of separation?

It is the last day the person was on the books (the last day of employment), written in box 5 of the employment insurance notification. It is one day earlier than the date health and pension coverage ends (the day after the last day). The form takes an era code (Reiwa is 5) and a 6-digit date: October 31, 2026 (Reiwa 8) is written “5-081031”.

What is the employment insurance loss of insured status notification?

It is the notification the employer files with Hello Work when an employee covered by employment insurance stops being insured, for example on leaving (Employment Insurance Act Article 7, Form No. 4). Filed with the separation certificate, it leads Hello Work to issue the separation notice, which the former employee needs to claim the basic allowance (unemployment benefit).

How do you file the employment insurance notification?

In person or by post at the Hello Work office for your workplace, or online through e-Gov. “Specified corporations”, such as companies with capital over 100 million yen, must file online. Attach documents showing the reason for leaving and the last day, and when a separation notice is wanted, prepare the separation certificate and the wage ledger too. It cannot be filed on the separation date itself.

What documents go with the notification?

For health and pension insurance with Kyokai Kenpo, attach any eligibility certificates and elderly recipient certificates that were issued, and file a non-return notification for any you cannot collect. With a health insurance society, nothing is attached to the Japan Pension Service notification. For employment insurance, attach documents showing the reason for leaving and the last day, such as a copy of the resignation letter and the attendance records, plus the separation certificate when a separation notice is wanted.

What if the employee has dependants?

Collect the dependants' eligibility certificates too, if issued, and attach them with the employee's. Dependants lose the company health insurance together with the employee, so after leaving they move to National Health Insurance, become dependants under voluntary continuation, or become dependants on another family member's health insurance.

What happens when an employee turns 70?

Employees' pension coverage ends at 70; health insurance continues until 75. When an employee turns 70 while working, you file the age-70 notification, not this one. If they keep working at the same office and their standard monthly remuneration does not change, the Japan Pension Service handles it and no age-70 notification is needed. When someone aged 70 or over leaves, fill in box (8), “no longer a 70+ employee”, on this notification.

Where do you get the voluntary continuation application?

Voluntary continuation (nin'i keizoku) is applied for by the former employee, not the company. With Kyokai Kenpo, they get the application form from its website or a branch and file it with the branch for their address within 20 days of the date coverage ends. With a health insurance society, they apply to that society. They must have been insured for at least 2 months in a row up to the last day, and coverage lasts up to 2 years.

Is there a filled-in sample of the health insurance notification?

Yes: the sample on this page (an employee leaving on October 31) and the official sample (PDF) published by the Japan Pension Service. When you fill in the template above, the filing sheet shows what goes in boxes (1) to (8), with the date coverage ends already in the era code (Reiwa is 9).

What is the confirmation of loss of insured status, and how do you fill it in?

The company does not fill it in: the Japan Pension Service or Hello Work sends it once the notification is accepted, as an electronic official document when you file online. Hand the employee's copy of the employment insurance confirmation to the former employee.

Is there a template in Excel, Word or English?

The Japan Pension Service publishes the official form as a PDF and an Excel file; Hello Work lets you print it blank or print it after typing in the details. On this page you can download, free, a filing sheet that sets out what goes on the form and a notice for the employee, as Word, Excel or PDF, in English or in Japanese (switch the preview to “Japanese”).

About the author

Emmanuel Gendre, founder of SaiyouTeam

Emmanuel Gendre

Founder, SaiyouTeam · HR and recruiting advisor to SMBs in Japan

  • Former Google recruiter
  • 12 years in talent acquisition

Emmanuel advises SMBs on HR and recruiting in Japan. Before founding SaiyouTeam, he spent 12 years in talent acquisition, including as a recruiter at Google. Clients often ask him about the paperwork when an employee leaves, so he built this free template to check the date coverage ends and the filing deadlines as you type.

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Related

Template library Employment separation templates The separation process and its deadlines, and every document from the resignation letter to the termination notice. Template Certificate of resignation The certificate you issue when a former employee asks for one; also used to show the last day when enrolling in National Health Insurance. Template Separation agreement For a departure agreed with the employee, including after an encouraged resignation (reason code 3 on the employment insurance notification). Template Termination notice The letter you hand over when dismissing an employee. A dismissal is reason code 3 (employer's reasons) on the employment insurance notification. Template Secondment agreement When the receiving company insures a seconded employee, the seconding company files this notification (reason code 1).

Official sources

This template and guide are based on the official sources below, where you can check the rules and forms.

Important. This template and guide are general information, based on the law and forms as of October 2026. File on the Japan Pension Service or Hello Work form (or online). This page's filing sheet is for checking what goes on the form and keeping a copy.