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["职工基本医疗保险缴费基数申报表"]
["单位名称（盖章）：                               单位编号：                       "]
["序号","人员编号","证件类型","证件号码","人员姓名","人员状态","月缴费工资","签字"]
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["单位经办人：                    移动电话：                      填报日期：        年    月    日        "]