全民健康保险保险对象退保(转出)申报告归纳
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~ Form No. Form writer L Application for withdrawal (transfer) from the National Health Insurance Branch Date declared 1 1 0 0 0 4 5 5 8 Taipei Branch Group Insurance Applicant Code Underwriter (Please ) Form No. ____ of date (mm/yy) Reason (Please) Insured Dependent Reason of Date of incident of withdrawal / transfer yy mm dd Approved Effective date BNHI） Last month of premium Original NHI IC Card No. yourself Name ID. No. （ARC No.） Name ID No. （ARC No.） transfer Transfer withdrawal / Withdrawal Dependent （to be fill in by payment ~ Descriptions 1. This form is used when the insured and the dependents are withdrawing or transferring from the NHI. The group insurance applicant will fill in one copy and submit it to the NHI branch in charge and keep a copy for future references. 2. Please fill in the reason of withdrawal according the following rules: (1)For those who have lost the eligibility for the insurance please state the code for the reason of withdrawal under the “Reason of withdrawal/transfer” column and tick “withdrawal”: for example, M-Deceased; E- Those who have been missing for six months or more; I- Those who are subject to criminal sanction and confined in the detention centers or prisons , or those who are subject to rehabilitative or reformatory disciplines longer than 2 months; O- Active military officers, noncommissioned officers, servicemen and military academy cadets;; U-Expired residency status, loss of household registry on exit from the country, loss of ROC nationality. (2)For those applying for change of group insurance applicant or change of insured status please tick “transfer” under the “Reason” column: such as when category 1 insured quits, retires, or has a business close down; category 2 insured withdraws; category 3 loses eligibility; category 4 loses status as the dependent of military officers; category 5 loses status as low income group or being placed in a different social welfare services institution; category 6 changes registered household certificate address or being placed in a different social welfare services institution, or when status of insured changes, when a dependent terminates the relationship of adoption, divorces, or when a dependent reaches the age of 20 but is not eligible or loses the eligibility for the insurance. 3. When the insured is withdrawn (transferred) from the NHI the dependents are automatically withdrawn/transferred, there will be no need to fill in the details of the dependents; when an individual dependent wishes to be withdrawn/transferred from the BHI the details of the insured should be supplied. 4. When the insured needs to withdraw or transfer out from the NHI due to change of Group Insurance Applicant or change of insurance status, the original group insurance applicant shall make a copy of this application form for the applicant to submit to the new groups insurance applicant for application of transfer into the NHI. Name of Group Insurance Applicant National Taiwan University （Seal or stamp of the institution） Address of Group Insurance Applicant No. 1 Roosevelt Road, Sec. 4, Taipei, Taiwan Person-in-charge （Stamp） Tel Processed by （Stamp） Fax For BNHI use Application No.: Application Date: Processed: Data Key in: Data Verification: 31008-健保轉出申報表 本文来源：https://www.wddqw.com/doc/55f84c396037ee06eff9aef8941ea76e59fa4aa7.html