Notice for Maternity Benefits

(See Regulation 87)
To

Shri ……………………..
Address …………………

I, Mrs. ………………………….w/o ………………… aged …………………… r/o ……………. working as …………………. since ……………….. having Insurance No. …………………….. hereby give the notice of my pregnancy. My expected date of deliver is ……………. (Date)

Place :………. 											
Dated:……….
Signature