Employees’ State Insurance (General) Regulations, 1950
FORM 21: Maternity Benefit
CERTIFICATE OF EXPECTED CONFINEMENT
51 [Signature or thumb impression of the insured woman
Employer's Code No
Book No ____________
Serial No ____________
Stamp of the dispensary Insurance No. _______
I certify that I have examined you today and that in my opinion you may expect to be confined on or about _______________________*
Signature of midwife, if any.
Signature or counter-signature of Insurance Medical Officer
(Rubber stamp or name in block letters)
Any other remarks_______________________________________
*This date should not be more than fifty days later than the date of examination.