Maternity Benefit
Claim Form
I……………………….. Insurance No……………wife of/daughter of…………………… here claim maternity benefit with effect from the………….day of 20……
I hereby declare that I have ceased/shall cease to work for remuneration with effect from that date.
Present/last employer……………..
Department, shift and occupation……….
Present address……………….
Date………………..
Signature or thumb impression