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Employees’ State Insurance (General) Regulations, 1950

FORM 20: Maternity Benefit

[Regulation 87]


51 [Signature or thumb impression of the insured woman

Employer's Code No.

Stamp of the dispensary

Book No _____

Serial No _________

To ____________

    I certify that I have examined you today and that in my opinion you are pregnant and your pregnancy appears to be ____________ weeks old.

Signature of midwife, if any

Signature or counter-signature of Insurance Medical Officer

(Rubber stamp or name in block letters)

Date ____________

Employees'   State Insurance (General) Regulations, 1950 Back

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