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["第三者行為による傷病届"]
["項　　　　　目",null,null,null,null,null,null,null,null,null,null,null,"内　　　　　容"]
["（被保険者名等）\n届出者",null,null," 被保険者記号・番号 / 保険者名",null,null,null,null,null,null,null,null,"被保険者記号・番号",null,null,null,null,null,null,null,null,null,null,null,"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," 届出者情報",null,null,null," 氏名 / 生年月日",null,null,null,null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日"]
[null,null,null,"※国民健康保険は\n  世帯主、その他\n  は被保険者の\n　情報を記入",null,null,null,null,null,null,null,null,"氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null," 住所 / 電話",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(      )"]
["(受診者)\n被害者",null,null," 氏名 / 続柄 / 生年月日",null,null,null,null,null,null,"届出者の情報と同じ場合はチェック",null,"ふりがな",null,null,"",null,null,null,null,null,null,null,null," 届出者との関係",null,null,null,"生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏 名",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[null,null,null," 住所 / 電話",null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(      )"]
["(第三者)\n加害者",null,null," 氏　名",null,null,null,null,null,null,null,null,"ふりがな",null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏 名",null,null,""]
[null,null,null," 住所 / 電話",null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(       )"]
["事故発生状況",null,null," 事故発生日時",null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,"午前 / 午後",null,null,null,null,null,"時",null,null,"分頃"]
[null,null,null," 事故発生場所"]
[null,null,null," 労災保険対象の確認",null,null,null,null,null,null,null,null,"本件は、労災保険の給付対象となる業務上又は通勤中の事故ではありません。\n（※事故発生状況報告書・被害者の負傷状況欄で確認し、チェック）"]
["(加害者)\n自賠責保険",null,null," 保険会社名 / 保険契約者名",null,null,null,null,null,null,null,null,"保険会社名",null,null,null,null,null,null,null,null,null,null,null,"ふりがな"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏 名"]
[null,null,null," 登録番号 / 車台番号",null,null,null,null,null,null,null,null,"登録番号",null,null,null,null,null,null,null,null,null,null,null,"車台番号"]
[]
[null,null,null," 保険期間 / 自賠責証明書番号",null,null,null,null,null,null,null,null,"保険期間",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自賠責証明書番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,"",null,null,"年","","月","","日","～","",null,"年","","月","","日","第",null,null,null,null,null,"号"]
["任意保険(加害者)",null,null," 保険会社名 / 担当部署",null,null,null,null,null,null,null,null,"保険会社名",null,null,null,null,null,null,null,null,null,null,null,"担当部署"]
[]
[null,null,null," 取扱店所在地 / 電話",null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(       )"]
[null,null,null," 担当者名 / E-mail",null,null,null,null,null,null,null,null,"ふりがな",null,null,null,"",null,null,null,null,null,null,null,null,null,null,null," E-mail"]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏 名",null,null,null,""]
[null,null,null," 保険契約者名",null,null,null,null,null,null,null,null,"ふりがな",null,null,null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,"氏 名",null,null,null,""]
[null,null,null," 住所",null,null,null,null,null,null,null,null,"〒",null,""]
[null,null,null,null,null,null,null,null,null,null,null,null,""]
[null,null,null," 保険期間 / 契約番号",null,null,null,null,null,null,null,null,"保険期間",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"契約番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,"",null,null,"年","","月","","日","～","",null,"年","","月","","日","第",null,null,null,null,null,"号"]
[null,null,null," 任意対人一括の有無",null,null,null,null,null,null,null,null,"有 ／ 無"]
[" 被害者加入の保険\n 会社の関与",null,null,null,null,null,null,null," 関与の有無を\n チェックし、\n 「有」の場合\n は右欄を記入",null,null,null,"保険会社名",null,null,null,null,null,null,null,null,null,null,null,"担当部署"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"担当者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," TEL"]
[null,null,null,null,null,null,null,null,"有",null,"無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(       )"]
["治療状況",null,null," 診療機関名 / 入院 / 治療期間",null,null,null,null,null,null,null,null,"① 診療機関名",null,null,null,null,null,null,null,null,null,"入　院",null," 治療開始日",null,null,null,"",null,"年","","月","","日"]
[null,null,null,null,null,null,null,null,null,null,null,null,"",null,null,null,null,null,null,null,null,null,"有 / 無",null," 治療終了(見込)",null,null,null,null,null,"年","","月","","日"]
[null,null,null," 住所 / 電話番号",null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(       )"]
[null,null,null,"  ※治療終了日（見込）については\n　  可能な範囲でご記入ください。",null,null,null,null,null,null,null,null,"② 診療機関名",null,null,null,null,null,null,null,null,null,"入　院",null," 治療開始日",null,null,null,"",null,"年","","月","","日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有 / 無",null," 治療終了(見込)",null,null,null,"",null,"年","","月","","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," TEL"]
[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,null,null,null,null,null,"③ 診療機関名",null,null,null,null,null,null,null,null,null,"入　院",null," 治療開始日",null,null,null,"",null,"年","","月","","日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有 / 無",null," 治療終了(見込)",null,null,null,null,null,"年","","月","","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," TEL"]
[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,"(       )"]
[" 傷病届作成日 / 作成支援の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null," 本届出書を損害保険会社等（業務委託先を含\n む）の支援を受けて作成した場合はチェック"]
["（注）本書は、自賠責共済、任意共済の場合、自賠責保険、任意保険の各欄に「保険」を「共済」と読み替えてその内容をご記入ください。"]