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["工伤保险待遇申领表"]
["单位全称",null,"",{"$nulls":6},"单位编号",{"$nulls":3},""]
["工伤职工姓名",null,"",{"$nulls":6},"移动电话",{"$nulls":3},""]
["公民身份号码 \n(社会保障号）",null,""]
["其他证件类型",null,"",{"$nulls":4},"证件号码",null,null,""]
[null,"伤残待遇","□伤残津贴 □生活护理费 □一次性伤残补助金"]
[null,null,"□一次性工伤医疗补助金"]
[null,"工亡待遇","□丧葬补助金 □一次性工亡补助金 □供养亲属抚恤金"]
[null,"医疗待遇","□医疗费 □康复费 □辅助器具费 □住院伙食费"]
[null,null,"□交通费 □食宿费"]
["供养亲属信息","姓名","公民身份号码(社会保障号）",{"$nulls":8},"供养关系",null,null,"是否孤寡老人或孤儿\n（勾选√）",null,null,"移动电话"]
[null,"","",{"$nulls":8},"",null,null,"□",null,null,""]
[null,"","",{"$nulls":8},"",null,null,"□",null,null,""]
[null,"","",{"$nulls":8},"",null,null,"□",null,null,""]
[null,"","",{"$nulls":8},"",null,null,"□",null,null,""]
["本单位/本人承诺，所填写内容和提供材料真实准确有效，否则承担相应的法律责任。"]
["单位（盖章）/承诺人（签名） "]
["",null,"年  月   日"]
["说明："]