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["“冀中能源杯•第三届寻找感动中国的矿工活动”团体意外伤害保险被保险人信息填写表"]
["序号","被保险人姓名","单位名称","身份证件号码","性别","年龄\n(周岁)","职业","受益人（非本人时填写，多人时备注说明）",{"$nulls":3},"被保险人\n签字确认"]
[{"$nulls":7},"姓名","与被保险人关系","身份证件号码","受益份额\n比例"]
[1,"张××","××集团××矿","123456789000000000","男",38,"采煤工","该栏空缺按法定受益人赔付"]
[2,"王××","××集团××矿","123456789000000001","女",45,"技术员","李××","配偶","123456789000000002",{"v":0.4,"d":"40%"}]
[{"$nulls":7},"李××","子女","123456789000000003",{"v":0.4,"d":"40%"}]
[{"$nulls":7},"刘××","父母","123456789000000004",{"v":0.2,"d":"20%"}]
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["说明："]
["1.本名单是保险合同的组成部分，本公司根据上述名单承担保险责任。"]
["2.被保险人如有残疾或疾病，应在“健康状况”栏如实填写。"]
["3.受益人由被保险人指定。凡未填写受益人的，按法定继承人办理。",{"$nulls":7},"投保日期：    年   月   日"]

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