Maternity Benefit – Certificate Of Pregnancy 150 Legal Draft Template
| Category | Notices |
| Format | Rich Text |
| File name | Maternity Benefit – Certificate of Pregnancy-150.rtf |
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Maternity Benefit - Certificate of Pregnancy
Form 20
(Regulation 87)
(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.
Signature of midwife, if any.
……………………………………..
Signature or counter-signature
of Insurance Medical Officer.
Date ……………
Rubber stamp or name in block letters
*