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["芜湖市城镇职工生育保险待遇申请表"]
["单位名称（盖章）：",null,null,"单位所属区域（盖章）："]
[null,null,"□市直 □镜湖区 □鸠江区 □弋江区 □三山区 □开发区 "]
["职工姓名",null,null,"个人编号"]
["性   别",null,null,"单位编号"]
["身份证号码",null,null,"电    话"]
["以下两行为男职工未就业配偶信息"]
["配偶姓名"]
["身份证号码"]
["申请项目","□ 生 育",null,"   □ 流 产","□ 引 产",null," □计  生 "]
["出生医学证明编号"]
["审核项目\n（由经办机构填写）\n","生 育 医 疗 补 贴",null,"  □女职工     \n  □男职工配偶","□顺  产\n□剖腹产\n"]
[null,"生   育   津   贴",null,"   产假          天"]
[null,"人流（引产）补贴",null,"   □四月内流产\n   □四至七月流（引）产\n   □七月以上引产\n"]
[null,"计   生   补   贴",null,"   □上环术\n   □取环术"]
[null,"产检补贴"]
["单位经办人：          联系电话：                  申报日期：       年   月   日"]
[]
["审   核（经办机构）：         ",null,null,"       填  单（经办机构）："]
["说明："]
["1、本表一式一份由用人单位填写并盖章，申报生育费用须提供:发票原件、出院小结原件及复印件、费用清单原件及复印件、出生医学证明原件及复印件、医保卡原件及复印件。"]
["2、申报人流、计生费用需提供:发票原件、诊断证明原件及复印件、病历原件及复印件、结婚证原件及复印件、医保卡原件及复印件。"]
["3、申报产前检查费用需提供：发票原件、以及发票对应的病历或报告单原件及复印件"]
["4、当年生育待遇报销截止日期为次年7月底。"]