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FORM 8: FIRST CERTIFICATE (CONFIDENTIAL)

Regulations 57 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 ___________

Employer's Code No.

Insurance No _____________

Stamp of dispensary ________

I certify that I have examined you today and that in my opinion you now need medical treatment and attendance and abstention from work on medical grounds by reasons of ________

In my opinion you will be fit to resume work tomorrow / on ______________

Date ____________

Signature ____________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Any other remarks by the Medical Officer ________________________________

 

 

 

 

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