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[null,"事　故　発　生　状　況　報　告　書　"]
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[null,"事故証明書\n番　　　号",null,null,null,"第","",null,null,null,null,null,"号","当事者","甲\n（加害者）",null,null,"氏名",null,null,""]
[null,"自 動 車 の\n登 録 番 号",null,null,null,"",null,null,null,null,null,null,null,null,"乙\n（被害者）",null,null,"氏名",null,null,"",null,null,null,null,null,null,"運転・同乗・歩行・その他"]
[null,"天　　候",null,null,null,"晴・曇・雨・雪・霧・(   )",null,null,null,null,null,null,null,"交 通 状 況",null,null,null,"混雑・普通・閑散",null,null,null,null,"明  暗",null,null,null,"昼間・夜間・明け方・夕方"]
[null,"道 路 状 況",null,null,null,"  舗装：",null,"（してある・していない）",null,null,null,null,null,null,null,"・","歩道：",null,"（ある・ない）",null,null,null,null,"・","道路の見通し：",null,null,null,null,"（良い・悪い）"]
[null,null,null,null,null," 中央車線：",null,null,null,"（ある・ない）",null,null,null,"・","道路の状況：",null,null,null,"（直線・カーブ・平坦・坂・積雪路・凍結路）"]
[null,"信号又は標識",null,null,null,"  信号：",null,"（ある・ない）",null,null,null,null,"・","自車側信号：",null,null,null,"（青・赤・黄）",null,null,null,null,"・","相手側信号：",null,null,null,null,"（青・赤・黄）"]
[null,null,null,null,null," 駐停車禁止：",null,null,null,"（されている・されていない）",null,null,null,null,null,null,null,null,"・","その他標識：",null,null,null,"（","",null,null,null,null,null,null,null,"）"]
[null,"速　　度",null,null,null," 甲車両：",null,null,"",null,"km/h",null,"(制限速度",null,null,"",null,"km/h）",null,"・","乙車両：",null,null,"",null,"km/h",null,"(制限速度",null,null,"",null,"km/h）"]
[null,"事　故　現　場　状　況　図",null,"（右の記号を使って乙の立場で記入してください。また、車線数も正確に記入し、道路幅はｍで記入してください。）"]
["　"]
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[]
[]
[]
[]
[]
[]
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[null,"事故発生の状況（経緯）",null,""]
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[]
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[null,"被害者の負傷状況",null,"日",null,null,null,null,null,"□","出勤日",null,null,"□","休日（定休日・休暇を含む）",null,null,null,null,null,null,null,null,"□","その他",null,"（","",null,null,null,null,null,"）"]
[null,null,null,"時　間　帯",null,null,null,null,null,"□","勤務時間中",null,null,"□","通勤途上",null,null,"□","出張中",null,"□","私用",null,"□","その他",null,"（","",null,null,null,null,null,"）"]
[null,null,null,"場　　　所",null,null,null,null,null,"□","会社内",null,null,"□","道路上",null,null,"□","自宅",null,"□","その他",null,"（","",null,null,null,null,null,null,null,null,"）"]
[null,null,null," 労災特別加入※\n※社長、役員等の経営者が\n　加入する労災保険",null,null,null,null,null,"（被害者が代表取締役等の役員、経営者の場合のみ記入）",null,null,null,null,null,null,null,null,null,null,null,"□","加入有",null,null,"□","加入無"]
[null,"上記内容に間違いありません。　　　　　　　　　　　　　　　　　　　　　　　　　",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,"　※署名又は記名・押印"]
[null,"　　　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,"届出者(被保険者)　　：\n※未成年の場合は親権者等"]
[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,"印"]
[null,"(注)本書面に代わる同等の内容の書面がある場合には、その書面の提出をもって本書面の代わりとすることも可能です。ただし、その場合には、当該書面の余白部分に「上記内容に間違いありません」と記入した上、届出者に署名または記名押印をして貰ってください。"]