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["正",null,null,"健康保険　被保険者資格喪失届",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"常務理事",null,null,"事務局長",null,null,"部長",null,null,"課長",null,null,"課長補佐",null,null,"担当者"]
[]
[]
["令和",null,null,"年",null,"月",null,"日","提出"]
["提出者記入欄"]
[null,"事業所\n所在地",null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険の記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・黄色の部分に入力、チェックして印刷してください。入力、チェックされた箇所は、",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"副","に反映されます。"]
[]
[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,"・印刷する際は、「A４　両面（長辺綴じ）」で印刷してください。白黒でもカラーでも結構です。"]
[null,"事業所\n名　称"]
[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,"・セルを結合したり、列や行を追加・削除しないでください。リセットボタンが正常に動作しなくなります。"]
[null,"事業主\n氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"社会保険労務士記載欄"]
[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　等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・ご使用のプリンターにより、A４用紙に納まらない場合は列や行を追加・削除するのではなく、"]
[null,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　以下の方法で対応してください。"]
[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,"　　1）余白を調整する。"]
[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,"　　2）印刷を拡大・縮小する。"]
["被保険者１","①",null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"③"]
[null,"被保険者\n等番号",null,null,null,null,null,null,null,"(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",null,null,null,null,null,null,null,"(名)",null,null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　3）空欄の「行」の高さを調整する"]
[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,null,null,null,"  "]
[null,"④",null,null,null,null,null,null,null,null,null,null,null,"⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,null,"年",null,"月",null,"日)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"千円",null,null,null,null,null,"死亡","(令和",null,null,"年",null,"月",null,"日)",null,null,null,"添　 付",null,null,"枚",null,null,null,null,"前回入力した情報を保存している場合は、別人の情報が残るのを避けるため"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,"枚中",null,"滅　 失",null,null,"枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,false,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,null,"枚",null,null,null,null,"下のリセットボタンを押して、全て消去してから入力してください。"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",null,null,null,")",null,null,null,null,null,"社会保障協定",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,"↓"]
[]
["被保険者２","①",null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"③"]
[null,"被保険者\n等番号",null,null,null,null,null,null,null,"(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",null,null,null,null,null,null,null,"(名)",null,null,null,null,null,null,null,"生年\n月日"]
[]
[null,"④",null,null,null,null,null,null,null,null,null,null,null,"⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,null,"年",null,"月",null,"日)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"千円",null,null,null,null,null,"死亡","(令和",null,null,"年",null,"月",null,"日)",null,null,null,"添　 付",null,null,"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,"枚中",null,"滅　 失",null,null,"枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,null,"枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",null,null,null,")",null,null,null,null,null,"社会保障協定"]
[]
["被保険者３","①",null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"③"]
[null,"被保険者\n等番号",null,null,null,null,null,null,null,"(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",null,null,null,null,null,null,null,"(名)",null,null,null,null,null,null,null,"生年\n月日"]
[]
[null,"④",null,null,null,null,null,null,null,null,null,null,null,"⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,null,"年",null,"月",null,"日)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"千円",null,null,null,null,null,"死亡","(令和",null,null,"年",null,"月",null,"日)",null,null,null,"添　 付",null,null,"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,"枚中",null,"滅　 失",null,null,"枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,null,"枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",null,null,null,")",null,null,null,null,null,"社会保障協定"]
[]
["被保険者４","①",null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"③"]
[null,"被保険者\n等番号",null,null,null,null,null,null,null,"(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",null,null,null,null,null,null,null,"(名)",null,null,null,null,null,null,null,"生年\n月日"]
[]
[null,"④",null,null,null,null,null,null,null,null,null,null,null,"⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,null,"年",null,"月",null,"日)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"千円",null,null,null,null,null,"死亡","(令和",null,null,"年",null,"月",null,"日)",null,null,null,"添　 付",null,null,"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,"枚中",null,"滅　 失",null,null,"枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,null,"枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",null,null,null,")",null,null,null,null,null,"社会保障協定"]
[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,"東京金属事業健康保険組合"]
[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,"受付印"]
[]
[]
[]
[]
[]
[]
["2025-04-01"]
[]
[]
["記入方法"]
[]
[null,"提出者記入欄",null,null,null,null,"：","下図を参照し、健康保険の記号を入力してください。"]
[null,null,null,null,null,null,null,null,null,"健康保険の記号"]
[null,null,null,null,null,null,null,null,null,1234]
[]
[]
[null,"①被保険者等番号",null,null,null,null,"：","被保険者等番号を、必ず入力してください。"]
[null,"②氏名",null,null,null,null,"：","氏名を入力してください。フリガナはカタカナで正確に入力してください。"]
[null,"③生年月日",null,null,null,null,"：","生年月日は下図を参照し入力してください。"]
[null,null,null,null,null,null,null,null,null,"③",null,"1988-05-20"]
[null,null,null,null,null,null,null,null,null,"生年\n月日"]
[]
[]
[null,"④喪失年月日",null,null,null,null,"：","下図を参照し、喪失年月日を入力してください。"]
[null,null,null,null,null,null,null,"退職等による資格喪失",null,null,null,null,null,null,null,null,null,"退職日の翌日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"転勤の当日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"雇用契約変更の当日"]
[null,null,null,null,null,null,null,"死亡による資格喪失",null,null,null,null,null,null,null,null,null,"死亡日の翌日"]
[null,null,null,null,null,null,null,"75歳到達による資格喪失",null,null,null,null,null,null,null,null,null,"誕生日の当日"]
[null,null,null,null,null,null,null,"障害認定による資格喪失",null,null,null,null,null,null,null,null,null,"認定日の当日"]
[null,null,null,null,null,null,null,"社会保障協定による資格喪失",null,null,null,null,null,null,null,null,null,"社会保障協定発効の当日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"相手国法令の適用となった日の翌日"]
[]
[null,"⑤標準報酬月額",null,null,null,null,"：","退職時等の標準報酬月額を入力してください。"]
[null,"⑥喪失（不該当）原因",null,null,null,null,"：","下図を参照し、該当する項目にチェックしてください。退職・死亡の場合は、その当日の年月日を（　）内に入力してください。"]
[null,null,null,null,null,null,null,"退職等",null,null,null,null,"退職した場合、雇用契約の変更等により被保険者の適用対象外となった場合、退職後に継続して再雇用した場合"]
[null,null,null,null,null,null,null,"死亡",null,null,null,null,"死亡した場合"]
[null,null,null,null,null,null,null,"75歳到達",null,null,null,null,"75歳に到達したことで後期高齢者医療に該当し、健康保険の被保険者資格を喪失する場合"]
[null,null,null,null,null,null,null,"障害認定",null,null,null,null,"65歳以上75歳未満の方で、障害認定により後期高齢者医療に該当し、健康保険の被保険者資格を喪失する場合"]
[null,null,null,null,null,null,null,"社会保障協定",null,null,null,null,"社会保障協定により、相手国法令の適用を受け、被保険者資格を喪失する場合"]
[]
[null,"⑦備考",null,null,null,null,"：","該当する場合は入力、チェックしてください。"]
[]
["添付書類"]
[null,"　・資格確認書等（本人および被扶養者分）"]
[null,"　　※資格確認書等が回収できない場合は、『資格確認書等回収不能届』をご提出ください。"]
[null,"　・60歳以上の方で退職後の継続再雇用の場合"]
[null,"　　　　　ア.就業規則・退職辞令のコピー等退職日が確認できる書類および継続して再雇用されたことが確認できる雇用契約書のコピー"]
[null,"　　　　　イ.上記「ア」の書類が添付できない場合、事業主の証明書（退職日、再雇用日が記載され事業主印が押印されているもの）等"]
[]
["お知らせ　"]
[null,"　・保険料の負担は、資格喪失月の前月分までとなります。退職による資格喪失の場合、喪失日は退職日の翌日となるため、月末に退職した場合は"]
[null,"　　退職月分の保険料まで控除する必要がありますのでご注意ください。"]
[null,"　・退職後の健康保険の任意継続を希望する場合は、当健康保険組合にお問い合わせください。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["副",null,null,"健康保険　被保険者資格喪失確認通知書"]
[]
[]
["令和",null,{"$f":"IF(C4=\"\",\"\",C4)","v":""},"年",{"$f":"IF(E4=\"\",\"\",E4)","v":""},"月",{"$f":"IF(G4=\"\",\"\",G4)","v":""},"日","提出"]
["提出者記入欄",null,null,null,"　届書記入の個人番号に誤りがないことを確認しました。"]
[null,"事業所\n所在地",null,null,null,"〒",{"$f":"IF(G6=\"\",\"\",G6)","v":""},"","","",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健康保険の記号"]
[null,null,null,null,null,{"$f":"IF(F7=\"\",\"\",F7)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(V7=\"\",\"\",V7)","v":""},"",null,{"$f":"IF(Y7=\"\",\"\",Y7)","v":""},"","","","","",""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,{"$f":"IF(Y8=\"\",\"\",Y8)","v":""},"","","","","",""]
[null,"事業所\n名　称",null,null,null,{"$f":"IF(F9=\"\",\"\",F9)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,{"$f":"IF(Y9=\"\",\"\",Y9)","v":""},"","","","","",""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"",""]
[null,"事業主\n氏　名",null,null,null,{"$f":"IF(F11=\"\",\"\",F11)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,"社会保険労務士記載欄"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,"氏　名　等"]
[null,"電話番号",null,null,null,{"$f":"IF(F13=\"\",\"\",F13)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,{"$f":"IF(Y13=\"\",\"\",Y13)","v":""},"","","","","","","","","","","","","",""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","",null,{"$f":"IF(Y14=\"\",\"\",Y14)","v":""},"","","","","","","","","","","","","",""]
[]
["被保険者１","①",null,null,{"$f":"IF(E16=\"\",\"\",E16)","v":""},"","","","","②",null,null,null,{"$f":"IF(N16=\"\",\"\",N16)","v":""},"","","","","","",null,{"$f":"IF(V16=\"\",\"\",V16)","v":""},"","","","","","","③",null,null,{"$f":"IF(AF16=\"\",\"\",AF16)","v":""},"","","","","","","",""]
[null,"被保険者\n等番号",null,null,{"$f":"IF(E17=\"\",\"\",E17)","v":""},"","","","","(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",{"$f":"IF(N17=\"\",\"\",N17)","v":""},"","","","","","","(名)",{"$f":"IF(V17=\"\",\"\",V17)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AF17=\"\",\"\",AF17)","v":""},"","","","","","","",""]
[null,null,null,null,{"$f":"IF(E18=\"\",\"\",E18)","v":""},"","","","",null,null,null,null,{"$f":"IF(N18=\"\",\"\",N18)","v":""},"","","","","","",null,{"$f":"IF(V18=\"\",\"\",V18)","v":""},"","","","","","",null,null,null,{"$f":"IF(AF18=\"\",\"\",AF18)","v":""},"","","","","","","",""]
[null,"④",null,null,{"$f":"IF(E19=\"\",\"\",E19)","v":""},"","","","","","","","","⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,{"$f":"IF(E20=\"\",\"\",E20)","v":""},"","","","","","","","",{"$f":"IF(N20=\"\",\"\",N20)","v":""},"","","","",null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,{"$f":"IF(AB20=\"\",\"\",AB20)","v":""},"年",{"$f":"IF(AD20=\"\",\"\",AD20)","v":""},"月",{"$f":"IF(AF20=\"\",\"\",AF20)","v":""},"日)"]
[null,null,null,null,{"$f":"IF(E21=\"\",\"\",E21)","v":""},"","","","","","","","",{"$f":"IF(N21=\"\",\"\",N21)","v":""},"","","","","千円",null,null,null,null,null,"死亡","(令和",null,"","年","","月","","日)",null,null,null,"添　 付",null,{"$f":"IF(AM21=\"\",\"\",AM21)","v":""},"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,{"$f":"IF(AH22=\"\",\"\",AH22)","v":""},"枚中",null,"滅　 失",null,"","枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,"","枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",{"$f":"IF(P24=\"\",\"\",P24)","v":""},"","",")",null,null,null,null,null,"社会保障協定"]
[]
["被保険者２","①",null,null,{"$f":"IF(E26=\"\",\"\",E26)","v":""},"","","","","②",null,null,null,{"$f":"IF(N26=\"\",\"\",N26)","v":""},"","","","","","",null,{"$f":"IF(V26=\"\",\"\",V26)","v":""},"","","","","","","③",null,null,{"$f":"IF(AF26=\"\",\"\",AF26)","v":""},"","","","","","","",""]
[null,"被保険者\n等番号",null,null,{"$f":"IF(E27=\"\",\"\",E27)","v":""},"","","","","(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",{"$f":"IF(N27=\"\",\"\",N27)","v":""},"","","","","","","(名)",{"$f":"IF(V27=\"\",\"\",V27)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AF27=\"\",\"\",AF27)","v":""},"","","","","","","",""]
[null,null,null,null,{"$f":"IF(E28=\"\",\"\",E28)","v":""},"","","","",null,null,null,null,{"$f":"IF(N28=\"\",\"\",N28)","v":""},"","","","","","",null,{"$f":"IF(V28=\"\",\"\",V28)","v":""},"","","","","","",null,null,null,{"$f":"IF(AF28=\"\",\"\",AF28)","v":""},"","","","","","","",""]
[null,"④",null,null,{"$f":"IF(E29=\"\",\"\",E29)","v":""},"","","","","","","","","⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,{"$f":"IF(E30=\"\",\"\",E30)","v":""},"","","","","","","","",{"$f":"IF(N30=\"\",\"\",N30)","v":""},"","","","",null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,{"$f":"IF(AB30=\"\",\"\",AB30)","v":""},"年",{"$f":"IF(AD30=\"\",\"\",AD30)","v":""},"月",{"$f":"IF(AF30=\"\",\"\",AF30)","v":""},"日)"]
[null,null,null,null,{"$f":"IF(E31=\"\",\"\",E31)","v":""},"","","","","","","","",{"$f":"IF(N31=\"\",\"\",N31)","v":""},"","","","","千円",null,null,null,null,null,"死亡","(令和",null,"","年","","月","","日)",null,null,null,"添　 付",null,{"$f":"IF(AM31=\"\",\"\",AM31)","v":""},"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,{"$f":"IF(AH32=\"\",\"\",AH32)","v":""},"枚中",null,"滅　 失",null,"","枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,"","枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",{"$f":"IF(P34=\"\",\"\",P34)","v":""},"","",")",null,null,null,null,null,"社会保障協定"]
[]
["被保険者３","①",null,null,{"$f":"IF(E36=\"\",\"\",E36)","v":""},"","","","","②",null,null,null,{"$f":"IF(N36=\"\",\"\",N36)","v":""},"","","","","","",null,{"$f":"IF(V36=\"\",\"\",V36)","v":""},"","","","","","","③",null,null,{"$f":"IF(AF36=\"\",\"\",AF36)","v":""},"","","","","","","",""]
[null,"被保険者\n等番号",null,null,{"$f":"IF(E37=\"\",\"\",E37)","v":""},"","","","","(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",{"$f":"IF(N37=\"\",\"\",N37)","v":""},"","","","","","","(名)",{"$f":"IF(V37=\"\",\"\",V37)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AF37=\"\",\"\",AF37)","v":""},"","","","","","","",""]
[null,null,null,null,{"$f":"IF(E38=\"\",\"\",E38)","v":""},"","","","",null,null,null,null,{"$f":"IF(N38=\"\",\"\",N38)","v":""},"","","","","","",null,{"$f":"IF(V38=\"\",\"\",V38)","v":""},"","","","","","",null,null,null,{"$f":"IF(AF38=\"\",\"\",AF38)","v":""},"","","","","","","",""]
[null,"④",null,null,{"$f":"IF(E39=\"\",\"\",E39)","v":""},"","","","","","","","","⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,{"$f":"IF(E40=\"\",\"\",E40)","v":""},"","","","","","","","",{"$f":"IF(N40=\"\",\"\",N40)","v":""},"","","","",null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,{"$f":"IF(AB40=\"\",\"\",AB40)","v":""},"年",{"$f":"IF(AD40=\"\",\"\",AD40)","v":""},"月",{"$f":"IF(AF40=\"\",\"\",AF40)","v":""},"日)"]
[null,null,null,null,{"$f":"IF(E41=\"\",\"\",E41)","v":""},"","","","","","","","",{"$f":"IF(N41=\"\",\"\",N41)","v":""},"","","","","千円",null,null,null,null,null,"死亡","(令和",null,"","年","","月","","日)",null,null,null,"添　 付",null,{"$f":"IF(AM41=\"\",\"\",AM41)","v":""},"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,{"$f":"IF(AH42=\"\",\"\",AH42)","v":""},"枚中",null,"滅　 失",null,"","枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,"","枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",{"$f":"IF(P44=\"\",\"\",P44)","v":""},"","",")",null,null,null,null,null,"社会保障協定"]
[]
["被保険者４","①",null,null,{"$f":"IF(E46=\"\",\"\",E46)","v":""},"","","","","②",null,null,null,{"$f":"IF(N46=\"\",\"\",N46)","v":""},"","","","","","",null,{"$f":"IF(V46=\"\",\"\",V46)","v":""},"","","","","","","③",null,null,{"$f":"IF(AF46=\"\",\"\",AF46)","v":""},"","","","","","","",""]
[null,"被保険者\n等番号",null,null,{"$f":"IF(E47=\"\",\"\",E47)","v":""},"","","","","(ﾌﾘｶﾞﾅ)\n氏名",null,null,"（氏）",{"$f":"IF(N47=\"\",\"\",N47)","v":""},"","","","","","","(名)",{"$f":"IF(V47=\"\",\"\",V47)","v":""},"","","","","","","生年\n月日",null,null,{"$f":"IF(AF47=\"\",\"\",AF47)","v":""},"","","","","","","",""]
[null,null,null,null,{"$f":"IF(E48=\"\",\"\",E48)","v":""},"","","","",null,null,null,null,{"$f":"IF(N48=\"\",\"\",N48)","v":""},"","","","","","",null,{"$f":"IF(V48=\"\",\"\",V48)","v":""},"","","","","","",null,null,null,{"$f":"IF(AF48=\"\",\"\",AF48)","v":""},"","","","","","","",""]
[null,"④",null,null,{"$f":"IF(E49=\"\",\"\",E49)","v":""},"","","","","","","","","⑤　標 準 報 酬 月 額",null,null,null,null,null,"⑥",null,null,"該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,"資格確認書等回収"]
[null,"喪　失\n年月日",null,null,{"$f":"IF(E50=\"\",\"\",E50)","v":""},"","","","","","","","",{"$f":"IF(N50=\"\",\"\",N50)","v":""},"","","","",null,"喪　失\n（不該当）\n原　因",null,null,null,null,"退職等","(令和",null,{"$f":"IF(AB50=\"\",\"\",AB50)","v":""},"年",{"$f":"IF(AD50=\"\",\"\",AD50)","v":""},"月",{"$f":"IF(AF50=\"\",\"\",AF50)","v":""},"日)"]
[null,null,null,null,{"$f":"IF(E51=\"\",\"\",E51)","v":""},"","","","","","","","",{"$f":"IF(N51=\"\",\"\",N51)","v":""},"","","","","千円",null,null,null,null,null,"死亡","(令和",null,"","年","","月","","日)",null,null,null,"添　 付",null,{"$f":"IF(AM51=\"\",\"\",AM51)","v":""},"枚"]
[null,"⑦",null,null," 該当する項目にチェックを入れてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75歳到達",null,null,"(健康保険のみ喪失)",null,null,null,null,null,{"$f":"IF(AH52=\"\",\"\",AH52)","v":""},"枚中",null,"滅　 失",null,"","枚"]
[null,"備　考",null,null,null,null,"二以上事業所勤務者の喪失",null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"障害認定",null,null,"(健康保険のみ喪失)",null,null,null,null,null,null,null,null,"返不能",null,"","枚"]
[null,null,null,null,null,null,"退職後の継続再雇用者の喪失",null,null,null,null,null,null,null,"(",{"$f":"IF(P54=\"\",\"\",P54)","v":""},"","",")",null,null,null,null,null,"社会保障協定"]
[null,null,null,null,null,null,null,null,null,null,null,"提出された被保険者資格喪失届にもとづき、うえのとおり資格喪失が確認されたので通知します。"]
[]
[]
[]
[null,null,"　この書類の保険料"]
[null,null,"　は　　　　月分で"]
[null,null,"　計算いたします"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,null,"東京金属事業健康保険組合理事長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"この通知書を受け取りましたら、すみやかに確認された事項をそれぞれの被保険者に通知してください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"なお、被保険者の住所が明らかでないため通知できないときは、その旨を当組合へ連絡してください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"この通知書は完結となった日から起算して２年間は、事業主が保存してください。"]
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[null,"　この通知書でわからないことがあるときは当組合へお尋ねください。この処分に不服が"]
[null,"あるときは、処分があったことを知った日の翌日から起算して３か月以内に文書又は口頭"]
[null,"で社会保険審査官（地方厚生（支）局内）に対して審査請求をすることができます。また、"]
[null,"審査請求の決定に不服があるときは、再審査請求又は処分の取消しの訴えを提起すること"]
[null,"ができます。"]
[null,"　再審査請求は、審査官の決定書の謄本が送付された日の翌日から起算して２か月以内に"]
[null,"文書又は口頭で社会保険審査会（厚生労働省内）に対して行うことができ、処分の取消し"]
[null,"の訴えは、審査請求の決定があったことを知った日から６か月以内（再審査請求があった"]
[null,"ときは、その裁決があったことを知った日から６か月以内）に、健康保険組合を被告とし"]
[null,"て提起することができます。（ただし、原則として、決定又は裁決の日から１年を経過し"]
[null,"たときは、提起することができなくなります。）"]
[null,"　なお、審査請求があった日から２か月を経過しても決定がないときや、処分の執行等に"]
[null,"よる著しい損害を避けるため緊急の必要があるとき、その他正当な理由があるときは、審"]
[null,"査請求の決定を経なくても提起することができます。"]
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[null,null,null,null,null,null,null,"お問い合わせ先：東京金属事業健康保険組合"]
[null,null,null,null,null,null,null,"<本　　部>　電話　０３－３８６６－２８６５（業務部　適用課）"]
[null,null,null,null,null,null,null,"<多摩支部>　電話　０３－５８３９－２４４１（業務課）"]