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[{"$nulls":8},"常務理事","事務長","担　当","確　認"]
[]
[]
[]
[]
[null,null,null,"健康保険被保険者証",null,null,null,"紛失及び回収不能届"]
[]
[null,null,null,"資格確認書"]
[]
[]
[{"$nulls":6},"回収不能\n対象者名"]
["被保険者等　記号・番号",null,null,null,"－"]
["氏　　名"]
["生年月日",null,"昭和　・　平成　　　　年　　　　月　　　　日"]
["住　　所",null,"〒"]
["資格取得\n年 月 日",null,"昭和　・　平成　　　　年　　　　月　　　　日"]
["事 業 所 名 称"]
["　〃　所 在 地",null,null,"〒"]
["担当者記載欄","紛 失 事 由"]
{"$rows_empty":8}
["事業主記入","回収不能事由","\n　 1. 上記事由のため\n\n　 2. \n\n 　3. "]
[]
[null,"誓約","後日被保険者証、資格確認書を回収できた時は、ただちに事業主を通じて健康保険組合へ返納します。"]
[]
[]
[]
[{"$nulls":10},"令和　　　　年　　　　月　　　　日"]
[{"$nulls":6},"事業所の所在地","〒"]
[{"$nulls":6},"事業所名称"]
[{"$nulls":6},"事業主氏名"]
[]
[null,"中部アイティ産業健康保険組合理事長　　殿"]
[null,"１．","この届は、紛失等で被保険者証、資格確認書を返納することのできない場合に提出するものです。"]
[null,null,"健康保険資格喪失者の被保険者証、資格確認書を返納することができない場合も提出が必要です。"]
[null,"２．","この届を提出するときは、紛失者自身の始末書を添えること。"]
[null,"３．","本人が出社しない場合は、回収不能事由欄は具体的に記入すること。（資格喪失者等）"]