Form 14a – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 14A: Maternity Benefit for Sickness

[Regulation 89B]

CLAIM FOR BENEFIT

    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 no longer claim to be sick due to confinement from ______ day of _____19 ___ and I shall / did not take up any work for remuneration before that day.

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

Date ____________

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 other person renders himself liable to prosecution.

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

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