Notice under the Employee's State Insurance Act, 1948
| Updated at | March 2010 |
Certificate of Pregnancy
Maternity Benefit
Certified of Pregnancy
Book No.
Serial No.
To
Insurance No.
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.)
Dated................20............
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