No-Photo Health Insurance Card Application for Newborn’s First-time

Insurance, Applicant signature:

National Health Insurance Insurance Application Form for Category 6 Insured
As per Form 1 Date form filled in _______________ (YYYY/MM/DD)
A. The insured ( □ Also fill in insured person's National ID number, full name, identity__and dependency information
when only applying for dependent insurance and enrollment. )
Reason for
Identity
insurance Health
National ID number First Name
qualification insurance
Veteran's Represent
Date of birth Veteran surviving atives or
(see card Date of eligibility
Alien Resident Certificate
dependent Directions 4 already
ID No. heads of
Last Name household
for reason received
details)

Year Month Day

□ □ □ Year Month Day
Yes □
No □

Postal
Household code
address

Postal □ Same as household address

Mailing code
address

Contact Telephone:
E-mail @
number Cellphone:
B. Dependent(s)
Reason for Health
insurance insurance
Date qualified to be
National ID number First Name Date of birth Title Code qualification (see card
insured
Directions 5 & 6 already
(Alien Resident Certificate
for reason details) received
number)
Last Name Year Month Day Year Month Day

Yes □
No □

Yes □
No □
Yes □
No □
Yes □
No □

If for independent applicant under the age

C. Signature or seal of the insured: of 20, legal representative information and
(Seal) statement must be filled in.

Assignee's ID Legal
number: representative's ID
number:
Telephone: _ Telephone: _
Reason insured cannot Relationship with the
handle application in
insured:
person:

Assignee's signature or seal: Legal representative's signature or seal:

D. Insured unit review result (Seal) (Seal)

Fields of this form match the Yes □ Handling person's

Insured unit's stamp
documentation No □ signature or seal
 Insured unit's code: Insured unit's name:
Application form directions:
I. When the insured or his/her dependent is qualified for insurance, the insured shall fill out a copy of this
form and submit to the local household registration office in the district where he/she resides.
II. For first-time participants in National Health Insurance (such as newborn babies), please also fill out
the "Application Form for Health Insurance Card" to apply for a health insurance card.
III. Fill in the dependent's title and code according to the following standards:

Code 1 2 3 4 5 6 7 8 9 0 p
Veteran's other
Paternal Paternal Maternal Maternal Paternal Maternal
surviving Ward
grandparent grandchildgrandparent grandchild great-grandparentgreat-grandparent
Title Spouse Parent Child dependent
In case of intergenerational relationship insurance,please provide identification
documents or related statements

IV. List detailed reasons why the insured is eligible for insurance, for example: unemployed veterans,
household registration for six months, change of group insurance applicant, etc.
V. List detailed reasons why the dependent is eligible for insurance, for example: loss of insurance
eligibility as insured, newborn baby, marriage, household registration for six months, adoption, etc.
VI. For lineal blood descendants who are within the second-degree of relationship and 20 years old or
more, eligibility conditions for insurance are limited to the following. Fill in according to the codes
below:
Code S P A H G

New graduate who is

Being qualified as unemployed, within one
In school Holding a disability severely injured or year of school year end;
Custody order still
Cause without card and unable to ill under this Act or discharged from
in place
employment support oneself and unable to military service and
support oneself unemployed, within one
year of discharge
VII. When applying for insurance, bring ID card and household registration certificate; For veterans
(veteran's surviving dependents) and dependents 20 years old or more, relevant documents such as
veteran certificate (veteran's surviving dependent certificate) and student ID card must also be attached.
VIII. After the insured completes the registration with the valid health insurance card on the National Health
Insurance Administration website, once he/she logs into the NHIA official website with the registered
health insurance card and completes identification verification, he/she can apply for various convenient
services online without leaving the house or contacting the municipal office. More service items will be
included in the future:
(I) Personal Health Insurance Information Online Services:
1. Application for enrollment (limited to insured persons with no dependents), transfer,
suspension or resumption of insurance for Category 6 insured who are qualified to
participate in insurance at the municipal office.
2. Unpaid individual insurance premium inquiries, single predesignated payment transfers, and
electronic payment slip applications and downloads.
3. Application for lost health insurance card re-issuance along with application for the insured.
4. Checking health insurance subscription or withdrawal status - date of subscription or
withdrawal, insured amount, and dependent insurance information.
5. Changes to personal mailing address.
6. Online application for insurance premium payment certificate.
7. Online application for Chinese and English certificate of insurance participation
(II) My Health Bank: For individuals to inquire about medical information, medication records, and
personal premium payment status.