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FORM 10: INTERMEDIATE CERTIFICATE (CONFIDENTIAL) Regulations 59 and 89B Signature/thumb impression of insured person ____________ Deposit this certificate within 3 days with local office to avoid possible loss of benefit under regulation 64 Book No ______ Serial No ______ Stamp of the dispensary To __________________ Insurance No _________ Date of first certificate of spell of sickness or disablement ____________ I certify that I have examined you today and that in my opinion you have continued to need medical treatment and attendance and abstention from work on medical grounds, up to and including this day by reason of ____________ Date ___________ Signature ________________ Insurance Medical Officer (Rubber stamp or name in block letters) Any other remarks by the Medical Officer ____________________________ | |||||
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