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FORM 21: MATERNITY BENEFIT Regulation 88 CERTIFICATE OF EXPECTED CONFINEMENT Signature or thumb impression of the insured woman Employer's Code No Book No ____________ Serial No ____________ Stamp of the dispensary Insurance No. _______ To _________ I certify that I have examined you today and that in my opinion you may expect to be confined on or about _______________________ Signature of midwife, if any. Signature or counter-signature of Insurance Medical Officer (Rubber stamp or name in block letters) Any other remarks_______________________________________ This date should not be more than fifty days later than the date of examination. | |||||
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