Rules and Regulations of India

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FORM 21: Maternity Benefit

[Regulation 88]


51[Signature or thumb impression of the insured woman

Employer’s Code No

Book No ____________

Serial No ____________  

                                                                                       Stamp of the dispensary Insurance No. _______

To _________

    I certify that I have examined you today and that in my opinion you may expect to be confined on or about _______________________*

Signature of midwife, if any.

Signature or counter-signature of Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks_______________________________________

*This date should not be more than fifty days later than the date of examination.

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