Form 8 – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 8: First Certificate

(CONFIDENTIAL)

[Regulations 57 and 89B]

49[Signature/thumb-impression of insured person…………………………]

50[Deposit this certificate within 3 days with local office to avoid possible loss of benefit under regulation 64]

Book No ____________

Serial No ___________

51[Employer’s Code No.]

Insurance No _____________                                                      

Stamp of dispensary ________

    I certify that I have examined you today and that in my opinion you now need medical treatment and attendance and abstention from work on medical grounds by reasons of ________

*In my opinion you will be fit to resume work tomorrow / on 52[______________]

Date ____________                                                         

Signature ____________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks by the Medical Officer ________________________________

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