FORM 10: Intermediate Certificate
(CONFIDENTIAL)
[ Regulations 59 and 89B]
50[Signature/thumb impression of insured person ____________
53[Deposit this certificate within 3 days with local office to avoid possible loss of benefit under regulation 64]
Book No ______
Serial No ______
Stamp of the dispensary
To __________________
Insurance No _________
Date of first certificate of spell of sickness or disablement ____________
I certify that I have examined you today and that in my opinion you have continued to need medical treatment and attendance and abstention from work on medical grounds, up to and including this day by reason of ____________
Date ___________
Signature ________________
Insurance Medical Officer
(Rubber stamp or name in block letters)
Any other remarks by the Medical Officer ____________________________
