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["被保険者",{"$nulls":9},"　埋葬料（費）請求書"]
["被扶養者"]
["被保険者（請求者）が記入する欄","被保険者等\n記号・番号",null,null,null,"記号",{"$nulls":4},"番号",{"$nulls":4},"事 業 所 名"]
[]
[null,"記号番号が分からない場合はマイナンバーを記入してください。"]
[]
[null,"被保険者のマイナンバー記入欄"]
[]
[null,"被保険者氏名（請求者氏名）"]
[null,"連絡先",{"$nulls":8},"-",null,null,null,"-"]
[null,"被保険者住所\n（請求者住所）",{"$nulls":5},"〒",null,null,"-"]
[]
[null,"死亡された方",null,null,"被保険者との続柄",null,null,null,"本人・家族（",{"$nulls":4},"）","年齢",{"$nulls":8},"歳"]
[{"$nulls":4},"氏名",{"$nulls":9},"生年月日",{"$nulls":5},"年",null,"月",null,"日"]
[null,"死亡年月日",{"$nulls":5},"年",null,null,"月",null,null,"日","埋葬に要した費用",{"$nulls":9},"円"]
[null,"埋葬年月日",{"$nulls":5},"年",null,null,"月",null,null,"日","第三者行為",null,null,null,"はい",null,null,"・","いいえ"]
[null,"死亡原因（病名）"]
[]
["事業主が証明する欄","死　　亡　　者",null,null,null,"死亡者氏名",{"$nulls":8},"死亡年月日",{"$nulls":5},"年",null,"月",null,"日"]
[null,"被保険者・被扶養者"]
[null,"上記の通り相違ない事を証明する。"]
[]
[{"$nulls":5},"  　　　　　年　　　　月　　　　日"]
[]
[{"$nulls":11},"事業所名称"]
[{"$nulls":11},"事業主氏名"]
[]
[null,"※ご記入いただいた内容を訂正する場合は、訂正箇所を二重線で抹消し、正しい内容と証明者の氏名（サイン）をご記入ください。"]
[]
["振込金融機関名","□","マイナポータル等で事前登録した公金口座を利用します。（利用する場合は□にチェック、利用しない場合・被保険者死亡"]
[null,null,"のため被保険者名義以外の口座を利用する場合は下記の欄を記入。）"]
[null,null,"注）口座情報の反映には登録から数日を要します。"]
[{"$nulls":5},"銀行",{"$nulls":5},"本店",null,"預金種目","普通",null,"口座番号"]
[{"$nulls":5},"金庫",{"$nulls":5},"支店"]
[{"$nulls":5},"農協",{"$nulls":5},"出張所 "]
[null,"（フリガナ）",{"$nulls":14},"※被保険者（被保険者が死亡した場合は\n請求者）口座を指定してください。"]
[null,"口座名義人"]
[]
["備　　　　考"]
[]
["健保組合\n処理欄",null,"支払年月日",{"$nulls":7},"年",null,null,"月",null,null,"日","常務理事",null,"事務長",null,"担当",null,"確認"]
[null,null,"支　給　額",{"$nulls":12},"円"]
[null,null,"資　　　格",null,null,null,"取得",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":6},"喪失",null,null,null,"年",null,null,"月",null,null,"日",null,null,null," 受 付 日 付 印"]
["注）1.この請求書に死亡診断書（写）を添付してください。"]
[" 2.被保険者が死亡した場合、被保険者と生計維持関係がない人が、埋葬を行い請求する場合は、"]
["埋葬に要した費用の領収書と続柄のわかるものを死亡診断書（写）と合わせて提出してください。"]
[{"$nulls":24},"2024年12月更新 中部アイティ産業健康保険組合"]