FORM 11: Special Intermediate Certificate
(CONFIDENTIAL)
[Regulations 61 and 89B]
50[Signature or thumb impression of insured person ____________
54[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 having continued to need medical treatment and have remained incapable of work up to and including this day by reason of _____________
I further certify that, judging from your present condition your incapacity/sickness is of such a character that it will be unnecessary to see you for the purpose of treatment more frequently than once in ____________ weeks, and you will require medical treatment and will remain incapable of work at least up to the end of ____________ weeks from this date.
I propose to issue certificates in this form at the intervals stated above so long as your condition does not require more frequent attendance.
In my opinion you (should now)/ (need not yet) be referred to a Medical Board to determine if you are permanently disabled.
Date __________________
Signature ____________
Insurance Medical Officer
(Rubber stamp or name in block letters)
Any other remarks by the Medical Officer ________________________
