Form no. 6 (Re: Article 24, Article 25, Article 33) (A)
Labor insurance　Application Form
Act on Asbestos
Health Damage Relief
Continued project
Application Form for: Estimated/Increased Estimated
/Fixed Insurance Premium; General Contributions
Standard writing style
(including grouped terminable
businesses)
0
I declare as follows.
Type
※Modified item number
3
2
7
0
1
①Labor
insurance
number
Administration
4
Base number
Industrial classification
―
―
(ten thousand)
(thousand)
(hundred)
(ten)
(persons)
(hundred thousand)
Item6
Era name
day
―
④Number of permanent employees
(hundred thousand)
8
9
Addressed to:
③Date of business closure, etc. (Era name: 7 for Heisei)
month
7
Heisei (year) (month) (day)
Branch number
②Date of addition (Era name: 7 for Heisei)
year
6
To submit
Business type
Item2
Era name
5
※Classifications
Item1
Jurisdiction
3
※Input code
0
Jurisdiction (2) Re: Insurances
Prefecture
2
Read “Writing instructions” on page 3 before filling in this form.
Write in the OCR boxes in the standard writing style as shown above.
year
―
Item3
⑤Number of persons covered
by Employment Insurance
(ten thousand)
(thousand)
(hundred)
(ten)
(persons)
month
―
※Reason for business closure, etc.
day
―
⑥Number of elderly persons exempt
from insurance payment
(ten thousand)
(thousand)
(hundred)
(ten) (persons)
Item7
Item4
Item5
※Code for reason
for single
※Re: insurance
Item 8
Item10
Item9
(a)
⑩Fixed Insurance Premium/General Contribution amount (⑧×⑨)
⑨Premium/Contribution rate
(a)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(a)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item11
Item12
yen
thousand yen
For Industrial
Accident
Compensation
Insurance
For
employees
applicable for
Employment
Insurance
(b)
(b)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item13
Item14
yen
thousand yen
(c)
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
Item15
thousand yen
For (d)
elderly
employees
(ｄ)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(d)
Item16
Item17
yen
thousand yen
For
employees
applicable
for
premium
calculatio
e)
(f)
(g)
(h)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(h)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item18
Item19
yen
(i)
General Contribution
Note1
(ｂ)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(i)
(i)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item35
Item36
yen
thousand yen
Labor Insurance
Premium
(a)
(ｂ)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(a)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item20
Item21
yen
thousand yen
For Industrial
(b)
Accident
Compensation
Insurance
For
(c)
employees
applicable for
Employment
Insurance
For (d)
elderly
employees
e)
For
(f)
employees
(g)
applicable for
premium
(ｂ)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(b)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item22
Item23
yen
thousand yen
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
For Employment Insurance
Estimated/Increased Estimated Insurance Premium calculation breakdown
⑪Classification
Item24
thousand yen
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
Item25
thousand yen
(h)　one thousandth
(hundred trillion) (ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand)
(h)
(ten trillion) (trillion) (hundred million) (ten million) (million) (hundred thousand) (ten thousand) (thousand) (hundred) (ten) (yen)
Item26
Item27
yen
thousand yen
⑮Zip code of business owner (fill in if there is a change)
―
※Recalculation: yes or no
Item31
Note 1 General Contributions collected from businesses applicable to Labor Insurance, based on Act on Asbestos Health Damage Relief Article 35 Paragraph 1
Labor Insurance
Premium
⑧Premium/Contribution calculated basis amount
Note 2 Delayed payment of General Contributions is not permitted.
Period of calculation: from Heisei (year) (month) (day) to Heisei (year) (month) (day)
⑦Classification
For Employment Insurance
Fixed Insurance Premium calculation breakdown
(Please do not fold this form. If you need to fold it, fold at the folding mark ).
To: Tokyo Labor Bureau
⑯Telephone number of business owner (fill in if there is a change)
―
Item28
※Calculation bases inspection subject
Item32
※Data indication code
※Classification of Reentry
Item33
―
Item28
⑰Application for delayed payment
Item30
※Modified item
Item34
Please do not write \ before the sum in ⑧, ⑩, ⑫, and ⑭
⑱Applied Estimated Insurance Premium
yen
⑲Applied Estimated Insurance Premium
Period 2
Period 3
(g) Estimated Insurance
Premium((a) of ⑭ ÷ ⑰)
yen
(j) Estimated Insurance
Premium
((a) of ⑭ ÷ ⑰)
㉖Enrolled Labor Insurance
㉘Business
(a) Address
(b) Name
(h) Amount appropriated
((a) of ⑳ - (b) of ㉒)
yen
/ Amount appropriated
((b) of ㉒ - (h) of ㉒)
yen
(a) Industrial Accident
Compensation Insurance
(b) Employment Insurance
(i) Amount of payment for
Period 2((g) – (h))
yen
(l) Amount of payment for
Period 3
((j) – (k))
Special target business
(a) Applicable
(b) Unapplicable
yen
yen
(f) Amount of payment for
this period ((d) + (e))
yen
㉓Date of
Establishment of
Insurance Relation
㉕Business or work type
Zip code
㉙Business owner
㉒Amount of payment for each period
(a) Amount
(b)
((a) of ⑱ - ⑩)
(c)
((a) of ⑱ - ⑩)
((a) of ⑩ - ⑱)
㉑Increased Estimated Insurance Premium
⑳Deduction appropriate
Amount
Amount
yen
yen
((a) of ⑭ - ⑲)
d
of refund
yen
of
Period 1
(a) Estimated Insurance
(d) Labor Insurance
(e) General Contributions
(Initial
Premium((a) of ⑭ ÷ ⑰ +
(b) Amount appropriated
(c) Amount of shortage ((c)
Premium for this period((a)
((f) of ⑩) Note 2
period)
fractions of less than 1 yen
((a) of ⑳)
of ⑳)
- (b) or (a) + (c))
Pay in
after the next period)
yen
yen
yen
yen
full or
yen
Telephone number
㉔Reason for
business closure, etc.
(1)Closure
(2)Entrustment
(3)Separate (4) Other
(a) Address(For corporations,
the address of the main office)
(b) Name of business
(c) Name of business
owner(For corporations, the
name of the delegate)
Cutting line (Please do not cut off the first page.)
Name and seal or sign
Seal