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["外国人技能実習生総合保険/外国人技能実習修了者総合保険/特定技能外国人総合保険/外国人研修生総合保険"]
["保  険  金  請  求  書",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,"チェックボックスの判定"]
["2025年1月改定版",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,"請求日",null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["ジェイアイ傷害火災保険株式会社 御中",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,"（この書面は全て西暦でご記載ください）"]
[]
["在留カード記載の在留期間内の事故について、この書面に記載した内容に事実と相違ないこと、裏面に記載の事項を確認･同意し、保険金を請求します。"]
["下記「保険金支払指図欄」記載の口座への振込をもって保険金を受領したものと認めます。",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,"請求歴"]
[]
["今回は以前に保険金のご請求されたことのある\n病気やケガに関するご請求（継続治療など）でしょうか。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（「はい」の場合のみ）\n前回の照会番号",null,null,null,null,null,null,null,null,null,"-",null,null,null,null,null,null,null,null,false,false]
[]
["保険契約",null,"証券番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"-",null,null,null,null,"保険金請求者",null,"住所",null,null,null,"〒"]
[]
[null,null,"保険期間",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[null,null,"雇用開始日",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"会社名\n団体名\n氏名"]
[]
["被保険者",null,"氏名",null,null,"漢字"]
[]
[null,null,null,null,null,"カタカナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者"]
[]
[null,null,null,null,null,"アルファベット",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,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,"性別"]
[null,null,"性別",null,null,null,null,null,null,"生年\n月日",null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,"E-MAIL",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[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,"在留資格"]
[null,null,"在留資格",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"お支払い案内ハガキ送付先\n（予備欄・該当の場合のみ）",null,"◆上記「保険金請求者」以外へも\n保険金お支払い案内ハガキの送付が必要な場合は、\n下記に送付先をご記入ください\n（送付先は保険契約者または契約上の受入機関に限ります）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,false,false,false]
[]
[null,null,"業務内容\n従事している業種"]
[]
["委任状兼同意書",null,"◆下記に被保険者ご本人のサインが必要です◆",null,null,null,null,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,"・","私は裏面の内容に同意します。"]
[null,null,null,"・","我同意反面処述内容。"]
[null,null,null,"・","I hereby give my consent to the details on the reverse side.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"会社名\n団体名\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,null,null,"担当者"]
[null,null,null,null,null,null,null,null,"（パスポートと同じサインを記載してください）",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,"午前午後"]
["病気やケガの内容",null,"発症日※1",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,null,null,null,"時頃",null,"　※1 病気の場合は症状が現れた日時\n　  　 ケガの場合はケガをした日時",null,null,null,null,null,null,null,null,null,null,null,false,false]
[]
[null,null,"初診日",null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日","傷病名"]
[]
[null,null,"部位",null,null,null,null,null,"（選択してください）",null,null,null,null,null,null,{"$f":"IF(I42=\"その他（右に入力⇒\",\"(\",\"\")","v":""},null,null,null,null,null,{"$f":"IF(I42=\"その他（右に入力⇒\",\")\",\"\")","v":""},"＜ケガの場合＞\nケガの内容",null,null,null,null,null,"（選択してください）",null,null,null,null,null,null,{"$f":"IF(AC42=\"その他（右に入力⇒\",\"(\",\"\")","v":""},{"$f":"IF(AC42=\"目に異物\",\"別紙申告書要\",\"\")","v":""},null,null,null,null,{"$f":"IF(AC42=\"その他（右に入力⇒\",\")\",IF(AC42=\"歯牙破折（本数⇒\",\"本\",\"\"))","v":""}]
[]
[]
[null,null,"発生場所"]
[]
[null,null,"事故状況/症状"]
[]
[null,null,"ケガの場合は発生状況\n/病気の場合は症状を\n詳しくご記入ください"]
[]
[]
[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,"業務上"]
[null,null,"　●業務上（通勤中を含む）でのケガ・病気でしょうか。",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,false,false]
[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,"治療歴"]
[null,null,"　●今回の症状に関して以前に治療を受けたことがありますか。",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,"治療を受けていた時期",null,null,null,null,null,null,null,"年",null,null,"月頃",null,null,false,false]
[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,"治癒した時期",null,null,null,null,null,null,null,"年",null,null,"月頃",null,null,"他保険"]
[null,null,"　●同一の費用を補償する他の保険契約等はありますか。",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,"保険/共済等の会社名",null,null,null,null,null,"（",null,null,null,null,null,"）",null,false,false]
[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,"証券番号",null,null,null,null,null,"（",null,null,null,null,null,"）"]
["保険金支払指図欄",null,"金融機関",null,"＜ゆうちょ銀行の方＞",null,null,null,null,null,null,null,"記号（3桁）",null,null,null,null,null,null,null,null,null,"-","番号（末尾の1を除く7桁を入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"口座種類"]
[null,null,null,null,null,null,null,null,null,null,null,null,1,null,null,null,null,null,null,null,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[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,"（普通）",null,null,null,"銀行・支店・口座種類"]
[null,null,null,null,"＜その他の金融機関の方＞",null,null,null,null,null,null,null,"フリガナ",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,"口座\n種類",null,null,null,null,null,null,false,false,false,false,false,false]
[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,false,false]
[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,false,false]
[null,null,null,null,null,null,null,null,null,null,null,null,"金融機関コード（4桁）",null,null,null,null,null,null,null,"-","店番（3桁）",null,null,null,null,null,"-","口座番号（7桁）"]
[]
[]
[null,null,"＜すべての方＞",null,null,null,null,null,null,null,null,null,"◆通帳の見開き１ページ目をご確認の上、同様にご記入下さい(フリガナ/アルファベット)"]
[]
[null,null,"口座名義人"]
[]
[null,null,"　●口座名義人が保険金請求者または被保険者以外の場合に被保険者との関係をご記入ください⇒",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,"）"]
["請求額",null,"治療費用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"★下記（代表例）などお支払いの対象とならない請求の書類提出は不要です。\n ・初診日（病気）、事故日（ケガ）から180日を経過した以降の費用\n ・業務災害（労災事故）・歯科疾病・妊娠に関する症状・発病のない健康診断\n ・保険責任期間の開始前に受傷または発病していた傷病（持病、治療中の傷病など）\n ・病院側の指示や都合によらない本人希望の健康保険適用外費用"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜保険会社・代理店使用欄／受付日・通信欄＞"]
[null,null,"合計",null,null,null,null,null,{"$f":"IF(SUM(I73:V78)=0,\"\",SUM(I73:V78))","v":""}]

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[]
[]
[]
["ジェイアイ傷害火災保険株式会社    御中"]
[]
["１．保険金請求及び個人情報の取り扱いに関する同意"]
[null,"（１）","私は表面（前頁）の事案に関して、表面（前頁）の保険金請求者を代理人と定め、本件事故に係る外国人実習生総合保険（外国人研修生総合保険等）の請求及び受領に関する一切の権限を委任します。"]
[null,"（２）","私は貴社が本保険請求に関する私の個人情報を、保険引受・支払いの判断、本契約の履行、付帯サービスの提供、損害保険等貴社の取り扱う商品・各種サービスの案内・提供、アンケートの実施、等を行うために利用するほか、下記①から⑤まで、その他業務上必要とする範囲で、取得・利用・提供または登録を行うことに同意します。"]
[null,null,"①","ジェイアイ傷害火災保険株式会社が、上記業務のために、業務委託先（保険代理店を含みます。）、保険仲立人、医療機関、保険金の請求・支払いに関する関係先、等に提供を行い、またはこれらの者から提供を受けることがあること。なお、これらの者には外国にある事業者等を含みます。"]
[null,null,"②","ジェイアイ傷害火災保険株式会社が、保険制度の健全な運営のために、一般社団法人日本損害保険協会、損害保険料率算出機構、他の損害保険会社、等に提供もしくは登録を行い、またはこれらの者から提供を受けることがあること。"]
[null,null,"③","ジェイアイ傷害火災保険株式会社が、再保険契約の締結や再保険金等の受領のために、国内外の再保険会社等に提供を行うこと（再保険会社等から他の再保険会社等への提供を含みます。）があること。"]
[null,null,"④","ジェイアイ傷害火災保険株式会社が、国内外のグループ企業や提携先企業に提供を行い、その企業が取り扱う商品等の案内または提供を行うことがあること。なお、保健医療等の特別な非公開情報（センシティブ情報）については、保険業法施行規則により限定された目的以外の目的に利用しないこと。"]
[null,null,"⑤","ジェイアイ傷害火災保険株式会社が、契約の安定的な運用を図るために、保険金請求情報等を契約者に対して提供すること。"]
["２．医療機関の提供および事故調査に関する同意"]
[null,"私を診療または治療した全ての病院、医師および関係者、または本件事故に関する諸機関および関係者が、ジェイアイ傷害火災保険株式会社またはその指名する者に、私に関する全ての疾病、傷害または事故の記録を提供することを承認します。なお、本書の写真複写も同じ効力があると認めます。"]
["３．他の保険契約等の保険金請求に関する同意"]
[null,"私は同一の損害または費用に対して、支払責任を負う保険契約および他の保険契約等（保険契約、共済契約その他いかなる名称であるかを問いません。以下同様とします。）から、保険契約等で定められた保険金等の額を超えて支払いを受けた場合には、その超えた額を、ジェイアイ傷害火災保険株式会社または他の保険契約等の損害保険会社･共済等へ直ちに返還します（ジェイアイ傷害火災保険株式会社または他の保険契約等の損害保険会社･共済等から返還方法の指定があった場合には、その方法に従います。）。また、他の保険契約等がある場合、ジェイアイ傷害火災保険株式会社がその保険契約等の損害保険会社･共済等に対して、ジェイアイ傷害火災保険株式会社の負担すべき部分（他の保険契約等がないとする場合に各損害保険会社･共済等が支払うべき保険金等の額の合計額に対するジェイアイ傷害火災保険株式会社の支払うべき額の割合をてん補損害額に乗じて得た額）を超えて支払った額を求償することに同意します。"]
["致JI伤害火灾保险股份有限公司"]
[]
["1.关于理赔和处理个人信息方面的同意事项"]
[null,"(1)","关于正面（前页）的案件，本人指定正面（前页）所记载的保险金理赔申请人为代理人，委任有关本件事故的外国实习生综合保险保险金（外国研修生综合保险等保险金）的申请及领取的相关所有权限。"]
[null,"(2)","对于和本保险理赔相关的本人个人信息，我同意贵公司可将其用于保险的承保及理赔的判断、本合同的履行、附带服务的提供、贵公司经营的如损害保险等商品及各种服务的说明和提供，以及问卷调查的实施等。并同意在以下①～④以及其他业务的必要范围，进行获取、利用、提供以及登录。"]
[null,null,"①","为了进行上述业务，JI伤害火灾保险股份有限公司可向其业务委托单位（包括保险代理店）、保险中介、医疗机构、与保险金的理赔及支付相关的单位提供，或者从这些单位获取本人相关个人信息。并且包括位于国外的公司等。"]
[null,null,"②","为了保险制度的健全运营，JI伤害火灾保险股份有限公司可向一般社团法人日本损害保险协会、损害保险费率计算机构以及其他损害保险公司等提供、登录，或者从这些单位获取本人相关个人信息。"]
[null,null,"③","为了签订再保险合同以及领取再保险金等，JI伤害火灾保险股份有限公司可向国内外的再保险公司等提供（包括再保险公司等提供给其他再保险公司等）本人相关个人信息。"]
[null,null,"④","JI伤害火灾保险股份有限公司可向其国内外集团内部企业及合作企业提供本人相关个人信息，并且说明或提供该企业经营的商品等。此外，关于保健医疗等特殊非公开信息（敏感信息），不得用于保险业法施行规则限定的目的以外的用途。"]
[null,null,"⑤","JI伤害火灾保险股份有限公司为了保证保险合同的稳定运转，将向投保人提供保险理赔等信息。"]
["2.关于提供医疗服务和调查事故方面的同意事项"]
[null,"本人同意并授权，所有给本人进行过诊断或治疗的医院、医生及其相关人员，还有与本事故相关的各机构及其相关人员，可向JI 伤害火灾保险股份有限公司或其指定人员提供与本人有关的所有疾病、受伤或事故的记录。此外，本文件的复印件也具有同样的效力。"]
["3.关于其他保险等的理赔同意事项"]
[null,"我承诺，对于同一损失或费用，如果通过申请多个可以理赔的保险合同（不论是保险合同、互助合同或其他名称，下同），获得了超过保险合同所约定的保险金的数额，将把超出的金额立即返还给JI 伤害火灾保险股份有限公司或者其他保险合同的承保损害保险公司以及保险互助合作社等。（如果JI伤害火灾保险股份有限公司或其他保险合同的承保损害保险公司以及保险互助合作社等指定返还方法，将遵照执行。）\n此外，在有其他保险合同的情况下，同意JI伤害火灾保险股份有限公司就超出应当承担的部分，向其他保险的承保损害保险公司或保险互助合作社等进行求偿。在没有其他保险合同的情况下，则同意JI伤害火灾保险股份有限公司按照比例，计算其在所有损害保险公司或保险互助合作社等应当支付总金额中应当承担的部分，并就超出部分向对方进行求偿。\n"]
["To: JI Accident & Fire Insurance Co.,Ltd."]
[]
["1.AUTHORIZATION FOR INSURANCE CLAIMS AND MY PERSONAL INFORMATION"]
[null,"(1)","the  undersigned, authorize the claimant indicated on the front of this form to administer all authorities concerning the claim for and receipt of the compre- hensive insurance for foreign technical trainee, foreign trainee and post-foreign technical trainee pertaining to the accident described on the front of this form.\nI hereby give my consent to your company to acquire, use and offer my personal information concerning this insurance claim, within the scope necessary to achieve the following purposes of use.\n"]
[null,"(2)","JI Accident & Fire Insurance Co.,Ltd. uses personal information regarding this insurance claim in order to perform activities such as judgment on insurance underwriting or claim payouts, fulfillment of this insurance policy, provision of ancillary services, notification/pro- vision of the Company’s products/services such as nonlife insurance, and implementation of a questionnaire (hereafter referred to as “the Company’s Activities”). In addition, the Company acquires, uses, provides or registers such personal information to the extent the Company needs for its operations in the manners listed to below"]
[null,null,"①","JI Accident & Fire Insurance Co.,Ltd. may provide such personal information to its business contractors (including agents), insurance brokers, and parties involved in the claim/payment of insurance benefits (such as medical institutions, nonlife/mutual insurance companies, parties involved in the insured events, etc.), or receive such personal information from these parties for the Company’s Activities. These parties include businesses outside of Japan."]
[null,null,"②","JI Accident & Fire Insurance Co.,Ltd. may provide such personal information to or resister it with organizations such as The General Insurance Association of Japan, The Life Insurance Association of Japan, General Insurance Rating Organization of Japan, other nonlife insurance companies, etc., or receive such personal information from these organizations and companies to ensure sound operation of the insurance system."]
[null,null,"③","JI Accident & Fire Insurance Co.,Ltd. may provide such information to reinsurance companies, etc., in Japan or overseas (including provision of such information from a reinsurance company, etc., to another reinsurance company, etc.), in order to conclude reinsurance contracts or receive reinsurance benefits, etc."]
[null,null,"④","JI Accident & Fire Insurance Co.,Ltd. may provide such personal information to its group companies or partner companies in Japan or overseas, and they may use it for notification or provision of their products/services and judgment of such notification or provision."]
[null,null,"⑤","JI Accident & Fire Insurance Co.,Ltd. may provide information of the insured’s insurance claim, etc., to the policyholder to ensure the stable management of the insurance contract."]
["2. AUTHORIZATION FOR MEDICAL RECORDS AND INFORMATION ON THE CASE"]
[null,"I hereby authorize any hospital, physician, or other person who has attended or examined me, or any government authority or other person who is related  to the accident, to furnish JI Accident & Fire Insurance Co.,Ltd. or its authorized representative with any and all information or document with respect to any sickness/injury or accident. I accept that a photocopy of this authorization shall also be considered as effective and valid as the original."]
["3. AUTHORIZATION FOR INSURANCE CLAIMS FROM OTHER POLICIES"]
[null,"I agree that if I receive payments such as insurance payouts that exceed the amount of insurance money, etc., stated in the policy under which this claim is made or in any other policies, etc., (insurance contracts,mutual aid contracts or any other contracts under whatever name they are known and under which payouts,etc., are made to cover the same damage or cost; and the same applies in this contract) for the same damage or cost, I shall repay, without delay, the amount exceeding the insurance money, etc., to JI Accident & Fire Insurance Co.,Ltd. or to the other non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded. [lf JI Accident & Fire Insurance Co.,Ltd., other non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded, specify procedures for such repayment,I shall follow the procedures.]\nIn the case of the existence of other insurance contracts, etc., I agree that JI Accident & Fire Insurance Co.,Ltd. may claim any excess of the amount it is obliged to payout from the non-life insurance companies, mutual aid associations, etc., with which the relevant insurance contracts, etc., are concluded.\n"]

{"sheet":"リスト参照元","index":2,"n_rows":51,"n_cols":6,"rows_kept":51,"cut":false,"hidden":true,"merged":[]}
["ただの数字","現在","過去10年","過去18～50年","部位","症状"]
[1,{"$f":"YEAR(TODAY())","v":2025},{"$f":"B2","v":2025},{"$f":"$B$2-A18","v":2008},"頭部","打撲"]
[2,{"$f":"MONTH(TODAY())","v":3},{"$f":"$C$2-A2","v":2024},2007,"頸部","捻挫"]
[3,{"$f":"DAY(TODAY())","v":1},2023,2006,"胸","擦過傷"]
[4,null,2022,2005,"腹","切傷"]
[5,null,2021,2004,"背","火傷"]
[6,null,2020,2003,"顔面","骨折"]
[7,null,2019,2002,"右手","歯牙破折（本数⇒"]
[8,null,2018,2001,"左手","目に異物"]
[9,null,2017,2000,"右足","その他（右に入力⇒"]
[10,null,2016,1999,"左足","（選択してください）"]
[11,null,null,1998,"その他（右に入力⇒"]
[12,null,"前後5年",1997,"（選択してください）"]
[13,null,{"$f":"$C$19+A6","v":2030},1996]
[14,null,{"$f":"$C$19+A5","v":2029},1995]
[15,null,{"$f":"$C$19+A4","v":2028},1994]
[16,null,{"$f":"$C$19+A3","v":2027},1993]
[17,null,{"$f":"$C$19+A2","v":2026},1992]
[18,null,{"$f":"B2","v":2025},1991]
[19,null,{"$f":"$C$19-A2","v":2024},1990]
[20,null,{"$f":"$C$19-A3","v":2023},1989]
[21,null,2022,1988]
[22,null,2021,1987]
[23,null,2020,1986]
[24,null,null,1985]
[25,null,null,1984]
[26,null,null,1983]
[27,null,null,1982]
[28,null,null,1981]
[29,null,null,1980]
[30,null,null,1979]
[31,null,null,1978]
[32,null,null,1977]
[33,null,null,1976]
[34,null,null,1975]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]