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Employees’ State Insurance (General) Regulations, 1950

FORM 10: Intermediate Certificate


[ Regulations 59 and 89B]

50 [Signature/thumb impression of insured person ____________

53 [Deposit this certificate within 3 days with local office to avoid possible loss of benefit under regulation 64]

Book No ______

Serial No ______                                                                                       

Stamp of the dispensary

To __________________                                                                        

Insurance No _________

Date of first certificate of spell of sickness or disablement ____________

    I certify that I have examined you today and that in my opinion you have continued to need medical treatment and attendance and abstention from work on medical grounds, up to and including this day by reason of ____________

Date ___________                             

Signature ________________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks by the Medical Officer ____________________________

Employees'   State Insurance (General) Regulations, 1950 Back

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