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[null,null,null,null,null,"常務理事",null,null,"事務局長",null,null,"事務局次長",null,null,"業務課長",null,null,"係長",null,null,"伺　年　月　日",null,null,null,null,null,null,"取得\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,"支払決議書"]
[]
[]
[]
[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,"喪失\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[]
[null,null,null,null,null,null,"法定給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,null,null,null,"出産\n年月日",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[]
[]
[null,null,null,null,null,null,"付加給付",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円",null,"出　生　児　の　数",null,null,null,null,null,null,"生産または死産の別"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　単胎 ・多胎（　　児）",null,null,null,null,null,null,"生産 ・死産（妊娠　　 週）"]
[]
[]
[null,null,null,null,"※備考"]
[]
[]
[null,null,null,null,null,null,null,"被保険者",null,null,null,null,null,"出産育児一時金・付加金請求書"]
["添付書類"]
[]
[null,null,null,null,null,null,null,"家族"]
[]
["③","②","①"]
[]
["海外出産の場合は、渡航歴の分かる書類（パスポート写し等）並びに同意書","医療機関から交付される直接支払制度についての合意文書の写し","領収・明細書の写し"]
[null,null,null,null,null,null,"被保険者証\n記号番号",null,null,null,null,null,null,"－",null,null,null,"事業所の名称"]
[]
[]
[null,null,null,null,"被　保　険　者　が　記　入　す　る　と　こ　ろ"]
[]
[]
[null,null,null,null,null,null,"出産年月日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","出産児数",null,null,"死産児数",null,null,"妊娠経\n過期間",null,null,"妊　 娠",null,null,null,null,null,"ヶ月"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"人",null,null,"人"]
[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,"在胎数週",null,null,null,null,null,"週"]
[]
[]
[null,null,null,null,null,null,"\n出産した\n医療機関等\n",null,null,null,"名称",null,null,null,null,null,null,null,null,null,null,null,"所在地",null,"〒",null,null,"―"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"出産者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者と出生児との関係",null,null,null,null,null,null,"出生児が被保険者の被扶養者であるかどうか",null,null,null,null,null,"1. ある"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.被保険者",null,null,null,null,"2.被扶養者"]
[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,null,null,null,"2. ない"]
[]
[]
[null,null,null,null,null,null,"家族が出産したときはその方の",null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,"続柄",null,null,null,"生年\n月日",null,"昭和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[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,"平成"]
[]
[]
[null,null,null,null,null,null,"下記、被保険者として請求の場合はⓐ、家族として請求の場合はⓑをそれぞれ該当の場合記入してください。"]
[]
[null,null,null,null,null,null,"ⓐ",null,null,null,null,null,"記号",null,null,null,null,null,null,"番号",null,null,null,null,null,"保険者名","全国健康保険協会",null,null,null,null,null,null,null,null,null,"支部"]
[]
[]
[null,null,null,null,null,null,"被保険者が退職後６カ月以内に出産したときは現在加入している保険\n（現在の被保険者証）",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,"健康保険組合"]
[null,null,null,null,null,null,null,null,null,null,null,null,"被保険者名"]
[]
[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,null,null,"共済組合"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"事業所名"]
[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,null,null,"市区町村"]
[]
[]
[null,null,null,null,null,null,"ⓑ",null,null,null,null,null,"記号",null,null,null,null,null,null,"番号",null,null,null,null,null,"保険者名","全国健康保険協会",null,null,null,null,null,null,null,null,null,"支部"]
[]
[]
[null,null,null,null,null,null,"家族が出産日前６カ月前の間に勤務していたことがあるときはそのときに加入していた保険",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,"健康保険組合"]
[null,null,null,null,null,null,null,null,null,null,null,null,"事業所名"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,"共済組合"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"退職年月日",null,null,"平成",null,null,"年",null,null,"月",null,null,"日"]
[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,null,null,"市区町村"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和"]
[]
[null,null,null,null,null,null,"ⓐ ⓑ に該当するときはその保険から出産育児一時金の給付を受けているか",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1,","受けた／受ける予定",null,null,null,null,null,"2,","受けない"]
[]
[]
[]
[null,null,null,null,null,null,"上記のとおり請求します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"請求年月日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
[]
[null,null,null,null,null,null,"川口工業健康保険組合理事長　殿"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,"―",null,null,null,null,null,"電話番号",null,null,null,null,null,"（",null,null,null,"）"]
[]
[null,null,null,null,null,null,null,"被保険者の住所"]
[]
[]
[]
[null,"勤務先・医療機関等・市区町村・全国健康保険協会・他健保などに\n問い合わせをする場合があります。　"]
[null,null,null,null,null,null,null,"被保険者の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,"昭和",null,"平成",null,null,"年",null,"月",null,"日"]
[]
[]
[]
[]
[null,null,null,null,null,null,"委任状",null,null,null,null,"本申請書の提出を事業主へ委任します。（委任する場合は☑）"]
[]
[]
[null,null,null,null,null,null,null,null,null," 事業主を代理人として健康保険組合より支給される本請求金額全額の受取り方の件を委任いたします。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者の氏名"]
[]
[]
[]
[]
[null,null,null,null,null,null,"※退職後等の請求で、上記に委任しない場合は、川口工業健康保険組合にお申し出下さい。"]
[]
[]
[]
[null,null,null,null,null,null,"出産者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"出産年月日",null,null,null,null,"平成",null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,null,null,"医師・助産師又は市区町村長の証明するところ"]
[null,null,null,null,null,null,"出生児の数",null,null,null,null,"　単胎　・　多胎　（　　　　児）",null,null,null,null,null,null,null,null,"生産または死産の別",null,null,null,null,"　　生産　　・　　死産　（妊娠　　　　　週）"]
[]
[]
[null,null,null,null,null,null,"上記のとおり相違ないことを証明します。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,"医療施設の所在地"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療施設の名称"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師・助産師の氏名"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,"（",null,null,null,null,"）"]
[]
[null,null,null,null,null,null,"本　　籍",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"筆頭者名"]
[]
[]
[null,null,null,null,null,null,"母の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"出生年月日",null,null,"令和",null,"年",null,"月",null,"日"]
[]
[]
[null,null,null,null,null,null,"上記のとおり相違ないことを証明する。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,"市区町村長名"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"社　　会　　保　　険　　労　　務　　士　　記　　入　　欄　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"決裁日付印",null,null,null,null,null,"受付日付印"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"川口工業健康保険組合（2022.4）"]