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[null,null,null,"※いずれかにチェックを入れて下さい。"]
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["川口工業健康保険組合　理事長　　殿"]
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["対象者\n氏　名　",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,null,null,null,null,null,null,"対象者続柄"]
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["被保険者\n住所",null,null,null,null,null,null,null,null,null,"〒",null,null,null,null,null,null,"―"]
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["申請の事由\n※該当するものを\n選択してください",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,"毀損",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無余白"]
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[null,null,null,null,null,null,null,null,null,null,"※毀損、無余白の場合は、該当の証を添付してください。"]
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["【確認事項】\n■再交付後に、古い（紛失していた）保険証が見つかった場合は、古い方の保険証を必ずご返却ください。\n■保険証は病院等で受診する他、身分証明書として広く機能しています。紛失により悪用される可能性が\n　 ありますので、取り扱いに十分ご注意ください。\n■保険証を紛失、盗難にあった場合は必ず警察へ「遺失物届」または「被害届」を出して、受理番号証を\n　 控えておいてください。（万が一悪用された場合、不正使用されたことの証明になります。)"]
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["事業所の\n\n証　明",null,null,null,null,null,null,null,null,null,null,"上記被保険者は被保険者証・高齢受給者証を"]
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[null,null,null,null,null,null,null,null,null,null,null,"滅　　失\n毀　　損\n無余白",null,null,null,null,null,null,null,null,null,"　したことを証明します。"]
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["※万が一、紛失したこと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、\n充分ご注意くださいますよう、お願い致します。"]

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[null,null,null,"※いずれかにチェックを入れて下さい。"]
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["【確認事項】\n■再交付後に、古い（紛失していた）保険証が見つかった場合は、古い方の保険証を必ずご返却ください。\n■保険証は病院等で受診する他、身分証明書として広く機能しています。紛失により悪用される可能性が\n　 ありますので、取り扱いに十分ご注意ください。\n■保険証を紛失、盗難にあった場合は必ず警察へ「遺失物届」または「被害届」を出して、受理番号証を\n　 控えておいてください。（万が一悪用された場合、不正使用されたことの証明になります。)"]
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["事業所の\n\n証　明",null,null,null,null,null,null,null,null,null,null,"上記被保険者は被保険者証・高齢受給者証を"]
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[null,null,null,null,null,null,null,null,null,null,null,"滅　失",null,null,null,null,null,null,null,null,null,"　したことを証明します。"]
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[null,null,null,null,null,null,null,null,null,null,null,"き　損"]
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[null,null,null,null,null,null,null,null,null,null,null,"埼玉県川口市本町○○－△△"]
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["事業所名称",null,null,null,null,null,null,null,null,null,null,"△△△株式会社"]
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["事業主氏名",null,null,null,null,null,null,null,null,null,null,"株式　一郎"]
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["電話番号",null,null,null,null,null,null,null,null,null,null,"111",null,null,null,null,null,null,null,null,null,"（",null,"1111",null,null,null,null,null,null,null,null,null,")",null,"1111"]
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["※万が一、紛失したこと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、\n充分ご注意くださいますよう、お願い致します。"]