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["事故報告用紙"]
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["株式会社アライブ【あんしん】利用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"]
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["（FAX　03-3479-5322　TEL　03-3479-4334）"]
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[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"]
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["施設名",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："]
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["施設住所\n（連絡先）",null,null,null,null,null,null,"〒",null,null,null,null,"-"]
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["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"]
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["当事者住所\n（被保険者）",null,null,null,null,null,null,"〒",null,null,null,null,"-"]
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["本人のおケガ",null,null,null,null,null,null,"【ケガの状態】"]
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[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"]
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["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"]
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[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"]
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[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"]
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["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"]
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["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。"]