Rules and Regulations of India

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FORM 9: Final Certificate


[Regulations 58 and 89-A]

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 ___________                                                                              

Stamp of the dispensary

Serial No __________

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 _______________ cause group No _________________________

    *In my opinion you will be fit to resume work tomorrow/on 52[1_______________]

Date ____________

Signature ____________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks by the Medical Officer ____________________

*Delete if not applicable.

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