Employees’ State Insurance (General) Regulations, 1950
FORM 20: Maternity Benefit
CERTIFICATE OF PREGNANCY
51 [Signature or thumb impression of the insured woman
Employer's Code No.
Stamp of the dispensary
Book No _____
Serial No _________
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)