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[{"$nulls":38},"常務理事",null,null,null,"事務長",null,null,null,"係",null,null,null,"確認"]
[{"$nulls":7},"健康保険任意継続被保険者資格取得申請書"]
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["申 請 者 記 入 欄",null,"資格喪失時の\n被保険者等",{"$nulls":6},"記　号",{"$nulls":7},"番　号",{"$nulls":7},"記号番号が分からない場合はマイナンバーを記入してください"]
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[null,null,"フリガナ",{"$nulls":26},"生年月日",null,null,null,"昭・平・令",{"$nulls":5},"年",null,null,null,"月",null,null,null,"日",null,"性別"]
[null,null,"氏　名"]
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[null,null,"住民票住所",{"$nulls":6},"〒",null,null,null,"－",{"$nulls":19},"(連絡が取りやすい)\n電話番号",{"$nulls":10},"－",{"$nulls":4},"－"]
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[null,null,"居所",{"$nulls":6},"〒",null,null,null,"－",{"$nulls":20},"※住民票住所と居所が同じ場合は記入不要です"]
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[null,null,"資格喪失時の事業所名称",{"$nulls":30},"資格喪失日",{"$nulls":6},"令和",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
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[{"$nulls":40},"（退職日の翌日が資格喪失日です）"]
[null,null,"　　〃　　　所　在　地",{"$nulls":8},"〒",null,null,null,"－"]
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[null,null,"保険料納付方法\n（希望する方法を○で囲んでください）",{"$nulls":14},"１．毎月納入する。　　２．まとめて納付（前納）する。（ ６ヵ月分 ・ １２ヵ月分 ）"]
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[null,null,"資格確認書　発行要否\n※（注）参照",{"$nulls":17},"発行が必要",{"$nulls":4},"　（資格確認書（再）交付申請書の提出が必要となります）"]
[{"$nulls":18},"□"]
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[null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"提出",null,null,"※資格喪失日以降の日付でご申請ください。",{"$nulls":14},"※緊急連絡先は、申請者と同居ご家族以外の方をご記入ください。申請者と連絡が取れない場合は、緊急連絡先にご連絡いたします。"]
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[{"$nulls":33},"[緊急連絡先]"]
["健保処理欄",null,"資格取得年月日",{"$nulls":10},"年",null,null,null,"月",null,null,null,"日",null,"〔 受 付 印 〕",{"$nulls":9},"住　　所",null,null,null,"〒",null,null,null,"－"]
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[null,null,"資格喪失年月日",{"$nulls":10},"年",null,null,null,"月",null,null,null,"日"]
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[null,null,"標準報酬月額",{"$nulls":5},"喪失時",{"$nulls":5},"千円",null,"決定",null,null,null,"千円"]
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[null,null,"任継　記号-番号",{"$nulls":8},8888,null,null,null,"―"]
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[null,null,"任継資格喪失予定年月日",{"$nulls":11},"年",null,null,"月",null,null,"日"]
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["（注）",null,null,null,"資格確認書　発行要否について"]
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["　資格確認書の発行が必要な場合は「発行が必要」の□に✓を付し、併せて資格確認書（再）交付申請書をご提出下さい。"]
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["※以下に該当する場合に限ります。"]
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["　・マイナンバーカードを取得していない者、マイナンバーカードの返納者"]
[]
["　・マイナンバーカードを保有しているが健康保険証利用登録を行っていない者、利用登録解除を申請した者、利用登録解除者"]
[]
["　・マイナンバーカードの電子証明書の有効期限切れの者"]