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["ＬＰガス事業者賠償責任保険制度　事故報告書"]
[]
["報告者　　　　　　　　　　　　　　　　　　　　　　\n　　　　　　　　　　　　　　　　　　　　　　　　　様\n　（□被保険者　□扱者　□その他　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,"報告日　　　　　　　年　　　月　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"℡"]
[]
["『事故の内容をお聞かせください』"]
["保険種目\n（該当に○）",null,null,null,"　LPガス賠償責任",null,null,null,null,null,"販売事業者",null,null,null,null,null,"受託認定保安機関",null,null,null,null,null,"スタンド事業者",null,null,null,null,null,"配送事業者"]
[null,null,null,null,"ｽﾀﾝﾄﾞ保険ｵﾌﾟｼｮﾝ",null,null,null,null,null,"自動車管理者賠償",null,null,null,null,null,"盗難保険",null,null,null,null,null,"店舗休業保険",null,null,null,null,null,"動産総合保険"]
[null,null,null,null,"特約",null,null,null,null,null,"個人情報漏えい",null,null,null,null,null,"総合賠償",null,null,null,null,null,"労働災害総合"]
["事業者","名称",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業\n所名"]
[null,"住所",null,"　　　　　　　都道　　　　　　　　　　市区　　　　　　　　　　　町\n　　　　　　　府県　　　　　　　　　　郡　　　　　　　　　　　 　村　　",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\n者名"]
[null,"℡",null,null,null,null,null,null,null,"（配送事業者・受託事業者の場合）\n 委 託 販 売 事 業 者 名 ："]
[]
["事故発生日",null,null,null,null,"　　　　　　　平成　　　　　年　　　　　月　　　　　日　（　　）　　午前・午後　　　　時　　　　　分頃"]
["事故発生場所",null,null,null,null,"住　　所",null,null,null,"　　　　　　　都道　　　　　　　　　　市区　　　　　　　　　　　町\n　　　　　　　府県　　　　　　　　　　郡　　　　　　　　　　　 　村　　　　　　　　"]
[null,null,null,null,null,"名　　称"]
[null,null,null,null,null,"施設種類",null,null,null,"住居 ・ 共同住宅 ・ 旅館等 ・ 料理飲食店 ・ 事務所 ・ 学校 ・ 病院 ・ 集会所 ・ 作業所 "]
[null,null,null,null,null,null,null,null,null,"充填所 ・ 販売所 ・ 運搬中 ・ その他(　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　)"]
[null,null,null,null,null,"事故ＬＰガス\nの用途",null,null,null,null,null,null,null,null,null,null,"供給状況",null,null,null,null,"容器 ・ 貯槽 ・ バルク",null,null,null,null,null,null,null,null,"㎏　　　　ｔ",null,null,"本"]
["被害者と損害区分","人身損害","被　害　者　氏　名",null,null,null,null,null,null,null,"年令",null,"男女",null,"人　身　被　害　の　区　分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"区分",null,null,"傷害の程度・全治日数など"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死・ケガ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死・ケガ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"死・ケガ"]
[null,"器物損害","建物・器物等",null,null,null,"有・無",null,"損害見込　　　　　　　　　　　　円　　建物・器物名称　（　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"車両損害",null,null,null,"有・無",null,"損害見込　　　　　　　　　　　　円　　車名　（　　　　　　　　　）　　　　　登録番号 （　　　　　　　　　　　　　）"]
["事故概要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜事故見取図＞"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"官公庁\n届出",null,null,"警察\n消防",null,null,null,null,null,null,null,"担当官",null,null,null,null,"届出人",null,null,null,null,null,"届出日",null,null,null,null,"受理番号"]
[]
["依\n頼\n事\n項","官公庁届出",null,null,null,null,"再報告要\n\n\n\n\n\n＊必要項目に\n赤印する",null,null,null,null,"\n無断示談禁止","\n付\n保\n開\n示禁止","\n社\n保\n切\n替","\n密\n接\nな\n連\n絡\n要","\nお\n見\n舞\nい","\n葬\n儀\n参\n列","\n□\n保\n険\n金\n請\n求\n書","\n□\n事\n故\n証\n明","\n□\n示\n談\n書","依\n□\n示\n談\n金\n領\n収\n書","頼\n□\n修理見積書","書\n□\n写\n真","類\n□\n領\n収\n書","\n□\n診断書","\n□\n治療費明細書","\n□\n確認書",null,"書類発送\n\n\n否・要\n\n\n発送",null,null,"その他"]
[]
["『ご連絡ありがとうございました』",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"協会受付印",null,null,"保険会社受付印"]
[]
["（注）賠償事故の場合には、保険会社の承諾前に「示談」を行わないようご注意下さい。"]