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["健康保険 任意継続被保険者資格喪失申出書 兼 保険料還付請求書"]
[]
["被保険者記入欄","保険証の\n記号・番号",null,null,901,null,"－",null,null,null,"加入区分",null,"任意継続被保険者"]
[]
[null,"被保険者氏名",{"$nulls":8},"生年月日",null,"□昭和\n□平成",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,"喪失事由",null,null,"　以下の該当事由に☑してください"]
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[{"$nulls":4},"□","①就職等により他の健康保険（健康保険組合、協会けんぽ、共済等）に加入したため"]
[{"$nulls":5},"　※新規に発行された健康保険証のコピーを添付してください（被保険者のみで可）"]
[]
[{"$nulls":4},"□","②国民健康保険に加入するため"]
[]
[{"$nulls":4},"□","③家族の被扶養者になるため"]
[]
[{"$nulls":4},"□","④被保険者が死亡したため"]
[]
[null,"　上記の事由により任意継続被保険者の資格喪失を希望いたします。"]
[null,"　前納等により資格喪失月以降の保険料の納入がある場合は以下の口座に還付ください。"]
[null,null,"令和",null,"年",null,"月",null,"日",null,"住　所",null,"〒"]
[]
[{"$nulls":10},"氏　名"]
[]
[{"$nulls":10},"TEL"]
[null,"振込口座\n選択に☑",null,null,"□","①任意継続被保険者加入時に指定した振込口座を希望"]
[{"$nulls":4},"□","②その他の振込口座を希望"]
[{"$nulls":10},"銀行  ・  信用金庫",{"$nulls":8},"本 店   ・   支 店"]
[{"$nulls":10},"他（　     　   　　）",{"$nulls":8},"他（                     ）"]
[{"$nulls":5},"金融機関コード",{"$nulls":8},"支店コード"]
[{"$nulls":5},"普通","口座番号",{"$nulls":8},"口座名義\nカタカナ"]
[]
["添付書類","□","当健康保険組合が交付した健康保険証、限度額適用認定証等（被保険者、被扶養者）"]
[]
[null,"□","①の事由による喪失の場合は、新規に発行された健康保険証のコピー（被保険者のみで可）"]
[]
[]
["■注意事項\n・喪失事由①については新規の資格取得日（健康保険組合等への加入日）での喪失となります。\n・喪失事由②、③については健康保険組合の受付日（書類到着日）の翌月1日での喪失となります。\n　※手続き後に「喪失証明書」と喪失日までの健康保険証の代わりとなる「資格証明書」を発行いたします。\n・喪失事由④については死亡日の翌日の喪失となります。\n　※手続き後に「喪失証明書」を発行いたします。"]
[]
[]
[]
[]
[]
[]
["健保記入欄",null,null,"資格喪失年月日",null,null,null,"令和",null,"年",null,"月",null,"日","保険証回収枚数",{"$nulls":7},"枚"]
[]
[null,"健　　保　　組　　合",{"$nulls":10},"健保受付"]
[null,"決　裁",null,null,null,"処　理"]
[]
[]
[]
[{"$nulls":22},"TGK 2023.10"]