Employees’ State Insurance (General) Regulations, 1950
FORM 12A: Maternity Benefit for Sickness
CLAIM FOR BENEFIT
I _____________________ wife / daughter of _________________________ Insurance No _________ hereby state that because of sickness due to pregnancy / confinement / premature birth of child/miscarriage, have not been at work since _____________
*I no longer claim to be sick due to confinement from ____________ and I shall / did not take up any work for remuneration before that day.
I claim benefit accordingly, 1 desire payment in cash at local office/by money order.
Present employer (if changed)_____________________ department _______ present address, (if changed)______________________
Signature or thumb impression
Local office _________
*Delete whichever is not applicable.
Notes :1 . Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.
2. This Form should be completed and sent without delay to the appropriate local office.
3. A final certificate must be obtained before resuming work.