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[]
["9. 事故報告用紙"]
[]
[]
["株式会社アライブ【きょうされん】総合補償制度担当者　行き",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,"報告日",null,null,null,2,0,null,null,"年",null,null,"月",null,null,"日"]
[]
["（FAX　03-3479-5322　TEL　03-3479-4334）"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜代理店記入欄＞",null,null,null,null,null,null,"証券番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"直コン依頼日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"き",null,null,"－",null,null,null,null,null,"A",null,"B",null,"C",null,"代理店発送日"]
[]
["会員名\n（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,"フリガナ"]
[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,"ご担当者名："]
[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,null,null,null,null,null,null,null,null,null,"様"]
["会員住所\n（事業所住所）",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,"FAX",null,null,null,null,"（",null,null,null,null,null,"）"]
["事故当事者\n（被保険者）",null,null,null,null,null,null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,"加入タイプ"]
[null,null,null,null,null,null,null,"氏",null,"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,"様",null,"女","（","西暦",null,null,null,"年",null,null,"月",null,null,"日",null,null,null,"歳","）"]
["当事者住所\n（連絡先）",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,"FAX",null,null,null,null,"（",null,null,null,null,null,"）"]
["ご請求保険種目",null,null,null,null,null,null,null,null,"利用者・職員のおケガの補償",null,null,null,null,null,null,null,null,null,null,null,"個人の賠償事故の補償",null,null,null,null,null,null,null,null,null,null,null,"事業者の賠償事故の補償"]
[null,null,null,null,null,null,null,null,null,"事業所の設備・什器の補償",null,null,null,null,null,null,null,null,null,null,null,"事業所の事業用現金の補償",null,null,null,null,null,null,null,null,null,null,null,"事業所の情報漏洩の補償"]
["本人のおケガ",null,null,null,null,null,null,"【ケガの状態】"]
[]
[null,null,null,null,null,null,null,"【病院名】",null,"①",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入院",null,null,null,"／",null,null,"～",null,null,"／",null,null,"頃"]
[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,"通院",null,null,null,"／",null,null,"～",null,null,"／",null,null,"頃"]
[null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"入院",null,null,null,"／",null,null,"～",null,null,"／",null,null,"頃"]
[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,"通院",null,null,null,"／",null,null,"～",null,null,"／",null,null,"頃"]
["第三者への\n賠償責任保険\n\n\n（被害者名）\n（補償内容）",null,null,null,null,null,null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[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,null,null,null,null,null,null,null,null,"（",null,null,null,"歳","）","TEL"]
[null,null,null,null,null,null,null,"【対人賠償】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【対物賠償】"]
[null,null,null,null,null,null,null,null,"・けがの状態",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・こわれた物"]
[null,null,null,null,null,null,null,null,"・病院名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・修理業者名"]
[null,null,null,null,null,null,null,null,null,"入院",null,null,"通院",null,null,"治癒見込み",null,null,null,null,null,"月",null,null,"日頃",null,"・修理業者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,"・修理見積り金額",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"円"]
["事故日",null,null,null,null,null,null,null,20,null,null,null,"年",null,null,"月",null,null,"日","（",null,null,"）",null,null,"午前",null,null,"午後",null,null,null,null,"時",null,null,null,"分頃"]
[]
["事故場所"]
[]
["事故内容\n（事故原因および状況）\n※事故の相手・ケガの状態など"]
[]
[]
[]
["他の保険契約等\n（ある場合）",null,null,null,null,null,null,null,"（保険会社名）"]
[null,null,null,null,null,null,null,null,"（保険種類）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（証券番号）"]
["※事故の日から30日以内にご通知のない場合には、保険金をお支払いできないことがありますのでご注意ください。"]