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FORM 23: MATERNITY BENEFIT

Regulations 88 and 89

CERTIFICATE OF CONFINEMENT OR MISCARRIAGE

Signature or thumb impression of the insured woman

Employer's Code No

Stamp of the dispensary

Book No ________

Serial No ________

I certify that I attended, ___________________________________________ Insurance no ______________ in connection with her confinement/ miscarriage at _____ (address) and that she was there delivered of a child on the _________ day of______________19__

Signature of midwife, if any.

Signature or counter-signature of Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks ______________________________________

 

 

 

 

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