Overseas Travel Insurance / J-TAS Application

There are 27 questions in this survey.

Overseas Travel Insurance / J-TAS Application

Student ID

Your answer

Have you completed the Declaration Form survey (link)?

Yes No

You cannot proceed with this survey.
Please complete the Declaration Form survey (link) first and return to this survey.

Choose one of the following answers

I will complete the Declaration Form survey and return to this survey.

Name

Your answer

Program

Choose one of the following answers

DUDP

Student Exchange

Summer Program

Independently Arranged Study Abroad

Host University

Your answer

Program Period (Example: March 18-31, 2019)

Choose one of the following answers

One year

One semester

Other:

Passport Number

Your answer

[Academic Calendar] First Day of Orientation

Date in the format: yyyy-mm-dd

Format: yyyy-mm-dd

1900-01-01

2037-12-31

[Academic Calendar] Last Day of Exams

Date in the format: yyyy-mm-dd

Format: yyyy-mm-dd

1900-01-01

2037-12-31

Have you already purchased your round-trip flight tickets?

Yes No

If you submit your insurance application before purchasing your flight tickets:

You should apply for the longest possible insurance coverage period to avoid having to extend the coverage period later on.
Please make sure to schedule your flights to fall within the insurance coverage period.
You must submit your E-tickets through the "Travel Itinerary Survey" as soon as you purchase them.

Choose one of the following answers

I acknowledged the above three conditions.

[Insurance Coverage Period] Departure Date from Japan

Date in the format: yyyy-mm-dd

Format: yyyy-mm-dd

1900-01-01

2037-12-31

[Insurance Coverage Period] Arrival Date in Japan

Date in the format: yyyy-mm-dd

Format: yyyy-mm-dd

1900-01-01

2037-12-31

Do you need to receive your Insurance Certificate urgently?

Yes No

I need the Insurance Certificate urgently because:

Check all that apply

I have to submit it for my visa application.

I have to submit it to my host university.

Other:

Preferred date to receive the Insurance Certificate

Date in the format: yyyy-mm-dd

Format: yyyy-mm-dd

1900-01-01

2037-12-31

*After submitting this form, you will receive an email from the Creotech Insurance Office within three working days informing you of the required payment amount.
*You will then need to arrange bank transfer to make the payment.
*Please note that it will take at least 7 working days to receive the certificate after APU receives the payment.
*Please note that you may not be able to receive the certificate on your preferred date.

Please select your preferred languages for your certificate of insurance.

(Please note that all students will receive a Japanese certificate as well.)

Check all that apply

English

French

German

Italian

Spanish

Chinese

korean

Are you able to pick up your insurance certificate from the Creotech office (building A 2nd floor) on campus?

Yes No

(Place to send insurance certificate) Postal code

Your answer

(Place to send insurance certificate) Address

Your answer

(Place to send insurance certificate) Telephone

Your answer

Please upload copies of your flight tickets.

Please upload at most 5 files

Upload files

Payment Methods

Choose one of the following answers

Domestic bank transfer

International money transfer

The payment will be made by:

Choose one of the following answers

The applicant

A proxy

The name of the proxy and the relationship to applicant.

	Name	Relationship to applicant:
Proxy	Name	Relationship to applicant:

Terms of Agreement

(International money transfer) International money transfers must take place in Japanese yen.
(International money transfer) All fees associated with international money transfers are the responsibility of the applicant, or of the proxy named above.
If we cannot confirm that the necessary funds have been received, or if the amount received is insufficient, we will require an additional payment.
If there is a change in the applicant’s insurance period, the office will send an email with instructions to complete the refund application. The applicant must complete the refund application within one month of receiving the aforementioned email. If the applicant does not complete the application within one month of receiving the email instructions, no refund will be issued.
As soon as the payment has been made, the applicant must complete the Insurance Payment Report.

Choose one of the following answers

I fully agree to the above terms and wish to proceed with my insurance application.

Are you sure you want to clear all your responses?