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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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