Employees' State Insurance (General) Regulations, 1950

FORM 13A: Maternity Benefit for Sickness

[Regulation 89B]

    I, _________ wife/ daughter of ____________ Insurance No _______ declare that, because of sickness due to pregnancy/confinement/premature birth of child/miscarriage, I have not been at work since the date of last/first certificate sent to you.

    I claimed benefit accordingly, I desire payment in cash at local office/by money order.

Date____                                                                                                                           

Present Address ______________

Signature or thumb impression

Local office _____________________

Notes : 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some person renders himself liable to prosecution.

2. This Form should be completed and sent without delay to the appropriate local office.

3. The insured person should obtain a final certificate before resuming work.]