Notice under the Employee's State Insurance Act, 1948

Updated to:March 2010
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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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