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[null,"健康保険",null,null,null,null,null,"被保険者",null,null,null,null,null,"埋葬料(費)支給申請書"]
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[null,null,null,null,null,null,null,"家　　族"]
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[null,"被保険者(申請者）情報",null,"被保険者（右づめ）",null,null,null,"記号",null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
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[null,null,null,"氏名",null,null,"(ﾌﾘｶﾞﾅ)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日は令和5年1月3日生まれの方は、05　01　03　とご記入下さい。"]
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[null,null,null,"住所",null,null,"〒",null,null,"ー"]
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[null,null,null,"電話番号",null,null,"TEL",null,null,null,null,"（",null,null,null,")"]
[null,null,null,"(日中の連絡先)"]
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[null," 事業主記入欄",null,"　事業所所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
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[null,null,null,"〒",null,null,"ー"]
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[null,null,null,"     事業所名称",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"      事業主氏名"]
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[null,null,null,"TEL",null,null,null,"（",null,null,"）"]
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[null,null,null,null,null,null,null,"この届出については、記載内容について誤りがないか事業主が"]
[null,null,null,null,null,null,null,"確認している。"]
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[]
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[null,null,"※　□　確認している場合は、レ点チェックをして下さい。"]
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[null,null,"※　資格喪失後の支給分については、別紙　振込先指定口座の用紙を"]
[null,null,null,"  提出して下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付日付印"]
[]
[null,null,"※　記入漏れ等、不備がありましたら返却させて頂きます。"]
[null,null,"　　それに伴い、給付金のお支払いも遅れる場合がありますのでご了解願います。"]
[]
[null,null,"社会保険労務士の　　提出代行者名記載欄"]
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[]
[]
["報徳同栄健康保険組合"]

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["健康保険 ",null,null,null,null,null,null,null,null,null,null,"被保険者",null,null,null,null,null,null,"埋葬料(費)申請書"]
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[null,null,null,null,null,null,null,null,null,null,null,"家　　族"]
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[]
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["被保険者氏名"]
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[]
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["　申請内容",null,null,null,null,null,null,null,null,null,"死亡年月日",null,null,null,null,null,null,null,null,null,null,null,null,"死亡要因",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"第三者の行為によるものですか"]
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[null,null,null,"死亡した方の",null,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,"いいえ"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"｢はい｣の場合は｢第三者の行為による傷病届｣を"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  提出してください。"]
[null,null,null,"●家族(被扶養者)が死亡したための申請であるとき"]
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[null,null,null,"ご家族の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,"被保険者　との続柄"]
[]
[]
[]
[]
[null,null,null,"亡くなられた家族は、退職等により健康保険の資格喪失後に被扶養者の認定を"]
[null,null,null,"受けた方で、今回の請求は次に該当することによる請求ですか。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,null,"いいえ"]
[null,null,null,"①資格喪失後、3ヵ月以内に亡くなられたとき"]
[null,null,null,"②資格喪失後、傷病手当金や出産手当金を引き続き受給中に亡くなられたとき"]
[null,null,null,"③資格喪失後、②の受給終了後、3ヵ月以内に亡くなられたとき"]
[null,null,null,"｢はい｣の場合、家族が被扶養者認定前に加入していた健康保険の保険者名と　　          　　記号･番号をご記入ください。"]
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[]
[]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記号･番号"]
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[]
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[null,null,null,"●被保険者が死亡したための申請であるとき"]
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[null,null,null,"被保険者の　　氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者からみた",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"埋葬した年月日",null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請者との身分関係"]
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[null,null,null,"埋葬に要した　費用の額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,"法第3条第2項被保険者として支給を     受けた時はその金額(調整減額)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円"]
[]
[]
[]
[]
[null,null,null,"亡くなられた方は、退職等により健康保険組合の被保険者資格の喪失後に"]
[null,null,null,"家族の被扶養者となった方で、今回の請求は次に該当することによる請求ですか。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,null,"いいえ"]
[null,null,null,"①資格喪失後、3ヵ月以内に亡くなられたとき"]
[null,null,null,"②資格喪失後、傷病手当金や出産手当金を引き続き受給中に亡くなられたとき"]
[null,null,null,"③資格喪失後、②の受給終了後、3ヵ月以内に亡くなられたとき"]
[null,null,null,"｢はい｣の場合、資格喪失後に家族の被扶養者として加入していた健康保険の　　   　　　　保険者名と記号･番号をご記入ください。"]
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[]
[]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記号･番号"]
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[]
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[]
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["事業主証明欄",null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,"被保険者･被扶養者の別",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死亡年月日"]
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[null,null,null,"死亡した方の",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者",null,null,null,null,null,null,"被扶養者",null,null,null,null,"令和",null,null,null,null,"年",null,null,"月",null,null,"日 死亡"]
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[]
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[null,null,null,"上記のとおり相違ないことを証明する。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
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[null,null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,"ー"]
[null,null,null,"事業所所在地"]
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[]
[null,null,null,"事業所名称"]
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[null,null,null,"事業主氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,null,null,null,null,null,null,"（",null,null,null,null,"）"]
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[]
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["報徳同栄健康保険組合"]

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