FORM 23: Maternity Benefit
[Regulations 88 and 89]
CERTIFICATE OF CONFINEMENT OR MISCARRIAGE
51[Signature or thumb impression of the insured woman
Employer’s Code No
Stamp of the dispensary
Book No ________
Serial No ________
I certify that I attended, ___________________________________________
Insurance no ______________ in connection with her confinement/ miscarriage at _____ (address) and that she was there delivered of a child on the _________ day of______________19__
Signature of midwife, if any.
Signature or counter-signature of Insurance Medical Officer
(Rubber stamp or name in block letters)
Any other remarks ______________________________________
