Maternity Benefit - Certificate of Pregnancy

Form 20
(Regulation 87)

Signature/thumb impression of the Insured woman.
Employer’s Code No. …………………………………………………………………….
Book ……………………………
Stamp of the Dispensary

Serial No………..

To

I certify that I have examined you today and that in my opinion you are pregnant and your pregnancy appears to be ………………………………weeks old.

……………………………………..
Signature of midwife, if any.
……………………………………..
Signature or counter-signature
of Insurance Medical Officer.

Date ……………
Rubber stamp or name in block letters

*