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["工   伤  保  险  待  遇  申  请  表                                                                  ",{"$nulls":9},"附表22、"]
["单位名称（章）：",{"$nulls":6},"单位代码："]
["申\n\n请\n\n人\n\n填\n\n写\n","工伤职工姓名","身  份  证  号",null,"工  伤  保  险  号",null,"联  系  电  话",null,"地       址",null,"备      注"]
[]
[null,"待               遇             项           目",{"$nulls":3},"申报数额",null,"附件名称",null,"张数"]
[null,"医疗（康复）待遇 ","医疗费"]
[null,null,"鉴定费"]
[null,null,"康复费"]
[null,null,"辅助器具费"]
[null,null,"住院治疗工伤的伙食补助费"]
[null,null,"转到遵义地区以外就医的交通费"]
[null,null,"转到遵义地区以外就医的食宿费"]
[null,"伤残待遇：\n伤残等级（       ）\n护理等级（       ）","一次性伤残补助金"]
[null,null,"伤残津贴"]
[null,null,"护理费"]
[null,null,"伤残津贴与养老金差额"]
[null,null,"一次性医疗补助金（解除或终止劳动合同）"]
[null,"工亡待遇：\n因工死亡待遇（     ）\n停工留薪期内死亡（     ）\n停工留薪期满死亡（     ）","丧葬补助金"]
[null,null,"一次性工亡补助金"]
[{"$nulls":3},"供养亲属姓名","享受比例","抚恤金小计："]
[null,null,"供养亲属1："]
[null,null,"供养亲属2："]
[null,null,"供养亲属3："]
["填表说明：1、此表一试二份由申请人和社保机构填写，社保机构和申请人分别留存。2、伤残津贴、护理费、供养亲属抚恤金的备注项填写三项待遇的调整情况。"]
[]
[]
["申请经办人：                         申请日期：",{"$nulls":4},"社保机构（章）：",{"$nulls":3},"申报材料接收人："]

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[{"$nulls":3},"工伤医疗待遇拨付通知单",{"$nulls":5},"编号："]
["单位代码",null,"单位名称",null,"所属县名称",null,"姓名","性别","身份证号码"]
["工伤认定决定编号",null,null,"申报住院总费用",null,null,"附件"]
["扣除项目外费用明细"]
["工伤医疗待遇支付"]
[]
["社保经办机构签章",null,"社保负责人签章",null,"社保工伤保险部门负责人签章",null,null,"财务审核","经办人签章","领款人签章"]