書類 · 日本語
労災申請書
Workers' accident compensation claim form under Japan's rousai hoken system.
- Form type
- rousai
- Language
- Japanese (日本語)
- Archive source
- AMDA-IMIC Japan forms library, 2013–2024
About This Form
This page documents the 労災申請書 as provided in Japanese through AMDA-IMIC's multilingual forms library. The form is used for: workers' accident compensation claim form under japan's rousai hoken system..
Japan's rousai hoken (labor accident compensation insurance) is a government-managed program covering workers injured in the course of employment. Claims require documentation of the accident, the employer, and the medical treatment received. Foreign workers in Japan are covered by this system regardless of visa status or nationality. AMDA-IMIC produced this form in multiple languages because the claims process is conducted in Japanese and many foreign workers lack the language ability to complete standard forms without assistance.
For the original administrative forms in active use, contact the relevant Japanese institution directly — a hospital, employer, local health center, or labor bureau — depending on which form is needed. This reference documents the structure and purpose of the forms as they were used during the 2013–2024 period when AMDA-IMIC was operating.
Form Sections and Fields
The following sections and fields appear in the Japanese version of this form. Field labels are rendered here in English for reference; the original form presents them in Japanese (日本語).
- Injured worker's full name, date of birth, and nationality
- Employer name and address
- Industry type and worker's occupation
- Date, time, and location of the accident
- Description of how the accident occurred
- Type and location of injury (body part and injury description)
- Name of treatment facility and attending physician
- Date treatment commenced
- Number of days unable to work
- Type of benefit requested (medical expenses / lost wages / disability / death)
- Worker's signature and date
- Employer certification and seal
How to Obtain This Form
The forms documented on this site were originally distributed by AMDA-IMIC through its consultation service and language-specific subdomains. Since the center closed in 2024, the forms are no longer distributed through that channel. Equivalent forms for current use are available from the relevant Japanese institution: municipal health centers issue administrative forms, hospitals provide their own registration and appointment materials, and the Labor Standards Inspection Office supplies labor insurance documentation.