Notice under the Employee’s State Insurance Act, 1948

Certificate of Pregnancy
Maternity Benefit
Certified of Pregnancy

Book No.
Serial No.
To

Insurance No.

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.)
Dated …………….20…………