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[]
[]
[]
["健康保険　証（書）紛失届"]
[]
["【被保険者証・資格確認書・限度額適用認定証・高齢受給者証・特定疾病療養受療証】"]
[]
[]
[null,"川口工業健康保険組合　理事長　殿"]
[]
["被保険者情報",null,"被　　保　　険　　者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"資　格　取　得　年　月　日"]
[null,null,"記号",null,null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,"昭和\n平成\n令和",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,"氏　　　　名",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,null,null,null,null,null,null,null,"昭和\n平成",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,"住　所",null,null,"〒",null,null,null,"-"]
[]
[]
["対　　　　象　　　　者",null,"氏　　名",null,null,null,null,null,null,null,"続柄",null,"紛失した証(書)",null,null,null,null,null,null,null,null,"理　　由"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者証\n資格確認書（注）\n限度額適用認定証（注）\n高齢受給者証\n特定疾病療養受療証（注）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"滅失"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"毀損"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者証\n資格確認書（注）\n限度額適用認定証（注）\n高齢受給者証\n特定疾病療養受療証（注）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"滅失"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"毀損"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者証\n資格確認書（注）\n限度額適用認定証（注）\n高齢受給者証\n特定疾病療養受療証（注）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"滅失"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"毀損"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,"）"]
["【確認事項】"]
["◆","再交付後に、古い（紛失していた）証（書）が見つかった場合は、古い方の証（書）を必ずご返却ください。"]
["◆","証（書）を紛失、盗難により悪用された場合においても、自己責任となりますので、警察へ「遺失物届」または「被害届」を提出"]
[null,"して受理番号証を控えておいてください。（万が一悪用された場合は、不正使用されたことの証明になります。）"]
["(注)資格確認書、限度額認定証、特定疾病療養受療証の再交付を希望される場合は、各種(再)交付申請書も"]
[null," 合わせてご提出ください。"]
[]
["　上記対象者は、上記の理由にて該当の証（書）を紛失いたしました。これより事故等が生じた場合は、一切の責任を私が負う"]
["ことを誓います。"]
["令和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,"被　保　険　者　氏　名"]
[]
["　　上記の事由により該当の証(書)を紛失したことをお届けいたします。",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,"受付印"]
["　令和",null,null,null,"年",null,null,"月",null,null,"日"]
["事業所所在地",null,null,null,null,null,"〒",null,null,"－"]
[]
["事業所名"]
["事業主氏名"]