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["健康保険 任意継続被保険者資格取得申請書"]
[]
["被保険者記入欄","保険証の\n記号・番号",{"$nulls":4},"－",null,null,null,"提出日",null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":12},"　※退職日の 2週間前 から申請可能です"]
[null,"被保険者氏名",{"$nulls":8},"事業所名"]
[]
[null,"配偶者の有無\n該当に☑",null,null,"□","あり　配偶者の年間収入",{"$nulls":4},"約",null,"万円"," ※配偶者が社会保険の被保険者の場合は原則として扶養\n　している子女等は配偶者の扶養に変更となります。"]
[{"$nulls":4},"□","なし"]
[null,"被扶養者の有無\n該当に☑",null,null,"□","あり　継続して被扶養者とする者がいる。（別紙「被扶養者届」の添付が必要）"]
[{"$nulls":4},"□","なし　継続して被扶養者とする者はいない。または退職後は他の者に扶養を異動する。"]
[null,"住　所",null,null,"〒"]
[{"$nulls":7},"都","道"]
[{"$nulls":7},"府","県"]
[{"$nulls":4},"連絡の取れる電話番号",{"$nulls":4},"自宅","　　　－　　　　－",{"$nulls":5},"携帯","　　　－　　　　－"]
[{"$nulls":4}," ※退職後に転居を予定している場合はご記入ください。",{"$nulls":9},"転居予定日",{"$nulls":4},"月",null,null,"日頃"]
[{"$nulls":4},"〒"]
[{"$nulls":7},"都","道"]
[{"$nulls":7},"府","県"]
[{"$nulls":4},"連絡の取れる電話番号",{"$nulls":4},"自宅","　　　－　　　　－",{"$nulls":5},"携帯","　　　－　　　　－"]
[null,"\n被保険者名義\nの振込口座",null,null," ※健保組合からの給付金等をお振込みする口座となります。"]
[{"$nulls":10},"銀行  ・  信用金庫",{"$nulls":8},"本 店   ・   支 店"]
[{"$nulls":10},"他（　     　   　　）",{"$nulls":8},"他（                     ）"]
[{"$nulls":4},"金融機関コード",{"$nulls":9},"支店コード"]
[{"$nulls":4},"普通","口座番号",{"$nulls":8},"口座名義\nカタカナ"]
[]
[]
["事業所","被保険者の\n退職年月日",null,null,"令和",null,null,"年",null,"月",null,"日","被保険者の\n喪失年月日",null,null,"令和",null,null,"年",null,"月",null,"日"]
[]
[null,"被保険者の\n標準報酬月額",{"$nulls":7},"千円",null,null,"備　考"]
[]
[null,"※喪失日(退職日の翌日)の間違い、月額変更届の届出漏れなどないかご確認ください。"]
[]
["健保記入欄",null,null,"記号・番号",null,null,901,null,"－",null,null,null,"取得年月日",null,null,"令和",null,null,"年",null,"月",null,"日"]
[]
[]
["■注意事項\n※任意継続被保険者になるには法律により(1)資格喪失日の前日までに継続して2ヶ月以上の被保険者期間があること、\n　(2)資格喪失日(退職日の翌日)から「20日以内」に申請(健保組合に到達した日)することが必要です。\n※申請いただくと健保組合より保険料等のご案内をお送りいたします。保険料のお振込みが確認できましたら保険証を\n　発行いたします。\n※加入期間は資格喪失日から最長で2年間です。保険料は事業主負担がなくなり全額被保険者負担となります。\n※保険料の納付期日(毎月10日)に1日でも遅れた場合には資格喪失となりますのでご注意ください。\n※任意に資格喪失の申し出がなされた場合は、資格喪失申出書が受理された日（健保組合に到達した日）の翌月1日に\n　任意継続被保険者の資格を喪失することになります。\n"]
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[null,"健　　保　　組　　合",{"$nulls":10},"健保受付",{"$nulls":6},"事　業　所"]
[null,"決　裁",null,null,null,"処　理",{"$nulls":13},"責任者",null,"担当者"]
[]
[]
[]
[{"$nulls":22},"TGK 2023.10"]

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[]
[null,"任意継続被保険者　被扶養者現況届"]
[]
["引き続き被扶養者申請を希望される方がいる場合は、この用紙に記入の上、ご提出してください。",{"$nulls":43},"届出年月日",null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["被扶養者増または減の場合は、別途「被扶養者異動届」をご提出ください。"]
[]
["記号・番号\n（保険証左上に記載）",{"$nulls":10},"－",{"$nulls":12},"被保険者氏名",{"$nulls":4},"被扶養者の状況は下記の通り相違ありません。"]
[{"$nulls":32},"被保険者氏名"]
[]
["被扶養者氏名",{"$nulls":8},"性別",null,null,"続柄",null,null,"　フリガナ",{"$nulls":16},"例：長男、養女",{"$nulls":4},"　フリガナ",{"$nulls":16},"例：長男、養女"]
[]
["生年月日",{"$nulls":8},"年　　齢",{"$nulls":13},"年",null,null,null,"月",null,null,null,"日",{"$nulls":4},"歳",{"$nulls":8},"年",null,null,null,"月",null,null,null,"日",{"$nulls":4},"歳"]
[]
[]
["職　　　　　　　　業"]
[{"$nulls":19},"（",{"$nulls":15},"）",{"$nulls":5},"（",{"$nulls":15},"）"]
[{"$nulls":19},"（",{"$nulls":15},"）",{"$nulls":5},"（",{"$nulls":15},"）"]
["収入状況",null,null,"①給与収入"]
[null,null,null,"（今後１年間の給与収入見込み額）",{"$nulls":15},"（",{"$nulls":10},"）",{"$nulls":5},"円",{"$nulls":4},"（",{"$nulls":10},"）",{"$nulls":5},"円"]
[null,null,null,"②年金収入"]
[null,null,null,"（今後１年間の年金収入見込み額）"]
[{"$nulls":24},"（",{"$nulls":5},"）",{"$nulls":5},"円",{"$nulls":9},"（",{"$nulls":5},"）",{"$nulls":5},"円"]
[null,null,null,"③事業収入",{"$nulls":21},"（",{"$nulls":4},"）",{"$nulls":16},"（",{"$nulls":4},"）"]
[null,null,null,"（今後１年間の事業収入見込み額）",{"$nulls":11},"※収入から、減価償却・接待交際費・損害保険料・福利厚生費・青色申告特別控除を除いた額",{"$nulls":21},"※収入から、減価償却・接待交際費・損害保険料・福利厚生費・青色申告特別控除を除いた額"]
[{"$nulls":36},"円",{"$nulls":21},"円"]
[null,null,null,"④その他"]
[null,null,null,"（今後１年間のその他収入見込み額）",{"$nulls":15},"（",{"$nulls":10},"）",{"$nulls":5},"円",{"$nulls":4},"（",{"$nulls":10},"）",{"$nulls":5},"円"]
["世帯",null,null,"別居の場合の送金状況"]
[{"$nulls":22},"（",{"$nulls":7},"）",{"$nulls":5},"円/月",{"$nulls":7},"（",{"$nulls":7},"）",{"$nulls":5},"円/月"]
[]
["※事実と異なる内容はあった場合には、資格の取り消し、医療費等の返還請求をさせていただきます。\n※必要に応じて別途、書類の提出をお願いする場合があります。",{"$nulls":22},"健　保　組　合",{"$nulls":20},"健保受付",{"$nulls":6},"事業所"]
[{"$nulls":23},"決　　　裁",{"$nulls":5},"処　　　　理",{"$nulls":21},"責任者",null,null,null,"担当者"]
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[]
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[{"$nulls":58},"TGK 2019.05"]