Maternity Benefit

Notice of Pregnancy

Form 19
(See Regulation 87)

I,  …………………………………………. Insurance No. …………………………………… wife of/daughter of …………………………….. hereby give notice of pregnancy.

Present address
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
Present/last employee

Date …………….
Signature or thumb impression
Confidential

*