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Employees’ State Insurance (General) Regulations, 1950

FORM 23: Maternity Benefit

[Regulations 88 and 89]


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 attended, ___________________________________________

    Insurance no ______________ in connection with her confinement/ miscarriage at _____ (address) and that she was there delivered of a child on the _________ day of______________19__

Signature of midwife, if any.

Signature or counter-signature of Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other  remarks ______________________________________ 

Employees'   State Insurance (General) Regulations, 1950 Back

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