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FORM 20: MATERNITY BENEFIT Regulation 87 CERTIFICATE OF PREGNANCY Signature or thumb impression of the insured woman Employer's Code No. Stamp of the dispensary Book No _____ 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 (Rubber stamp or name in block letters) Date ____________ | |||||
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