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[null,null,null,"健康保険",{"$nulls":5},"第三者行為による傷病届"]
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[{"$nulls":20},"氏　　名",{"$nulls":5},"                                                      　　  "]
[{"$nulls":12},"番号　　　　"]
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[{"$nulls":26},"年  　 　月　   　日生 （　  　才）"]
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[{"$nulls":29},"　　    　TEL       　   -　             -"]
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[{"$nulls":4},"被保険者が勤務　　　している事業所　　　(連絡先）",{"$nulls":7},"名　　　称"]
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[{"$nulls":12},"所 在 地",{"$nulls":8},"〒",null,null,"-"]
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[{"$nulls":4},"被扶養者が被害者であるとき",{"$nulls":7},"フリガナ",{"$nulls":25},"続　柄"]
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[null,"事故相手",null,null,"加　害　者",{"$nulls":7},"フリガナ"]
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[{"$nulls":20},"　　　　　　　年　　月  　 日生 （    　 才）"]
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[{"$nulls":33},"TEL     　   -　           -"]
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[{"$nulls":12},"所 在 地"]
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[{"$nulls":21},"TEL       　   -　             -"]
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[{"$nulls":12},"場　　所"]
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[{"$nulls":4},"事故発生時の状況",{"$nulls":7},"被保険者又は被扶養者",{"$nulls":10},"自動車・バイク・自転車・歩行者・交通事故以外（　　　　　　　）"]
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[{"$nulls":12},"加害者（事故相手）",{"$nulls":10},"自動車・バイク・自転車・歩行者・交通事故以外（　　　　　　　）"]
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[{"$nulls":4},"過失の度合  　　         (わかる範囲で)",{"$nulls":7},"　自分（被害者）の過失",{"$nulls":10},"   ０．１０．２０．３０．４０．５０．６０．７０．８０．９０．１００　(%)"]
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[{"$nulls":12},"　相手（加害者）の過失",{"$nulls":10},"   ０．１０．２０．３０．４０．５０．６０．７０．８０．９０．１００　(%)"]
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[{"$nulls":4},"治療見込み\n（治療終了日）",{"$nulls":6},"年　　　月頃\n（　　　　　年　　月　　日終了）",{"$nulls":10},"（注）治療費の支払い区分を医療機関に確認して〇で囲んでください。\n治療が終了しているときは、最終受診日をご記入ください。 。　　　"]
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[{"$nulls":4},"後  遺  症",{"$nulls":6},"　　　　あ　　る 　・　 あ る 見 込 み 　・   な　い　・　 な い 見 込 み　 ・　 不　明"]
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[null,null,"＊注１",null,null,"物損事故で処理した場合,別途 「人身事故証明入手不能理由書」の提出を求める場合があります。"]
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[{"$nulls":11},"所  在  地",{"$nulls":6},"〒",null,null,"-"]
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[{"$nulls":32},"TEL       　   -　             -"]
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[{"$nulls":11},"証明書番号"]
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[{"$nulls":6},"任意保険",{"$nulls":4},"保険会社名",{"$nulls":22},"担当者"]
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[{"$nulls":22},"TEL     　   -　          -"]
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[{"$nulls":11},"証明書番号",{"$nulls":22},"＊注2"]
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[null,"被害者の人身傷害保険",{"$nulls":9},"加入の有無",{"$nulls":6},"有　・　無",{"$nulls":4},"   保険会社名　　　　　　　　　　　　　　　　             　　担当者"]
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[{"$nulls":32},"TEL           　   -　                  -"]
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[null,"休業補償",null,null,"      休業（治療）中の休業補償の方法（記号に〇をつける）\n\n    ア　加害者が負担　　       イ　職場から支給　          　ウ　自賠責へ請求\n\n    エ　健保へ傷病手当金　　オ　その他（被害者加入の人身傷害保険へ請求など）"]
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[null,"示談状況",null,null,"示談は成立していますか",{"$nulls":9},"　成立している",{"$nulls":10},"　　　　　　　年　　　　月　　　　日　　　　成　立"]
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[{"$nulls":14},"　成立していない・交渉中",{"$nulls":10},"　　　　　　　年　　　　月　　　　日　　　　現　在"]
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[{"$nulls":4},"請求権を放棄した場合",{"$nulls":9},"　　　　　　年　　　　月　　　　日",{"$nulls":11},"理　由"]
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[null,"損害賠償",null,null,"相手方に対する損害賠償の請求状況",{"$nulls":16},"　　　　　　　すでに請求済　・　現在のところ未請求"]
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[{"$nulls":4},"相手方からの損害賠償金等の受領状況",{"$nulls":16},"　　　 　　 　　　   受領済　　・　　受領していない"]
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[{"$nulls":4},"＊加害者や保険会社から賠償金を受領した場合のみ下欄にご記入ください。"]
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[{"$nulls":13},"見 舞 金",{"$nulls":6},"円",{"$nulls":9},"（合計額）",{"$nulls":12},"円"]
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[{"$nulls":4},"受  領  方  法",{"$nulls":8},"一　　括",{"$nulls":6},"　 　　　　　　　　年　　　　　月　　　　日　　　受　領"]
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[{"$nulls":7},"対応している場合です。"]