Maternity Benefit - Certificate of Pregnancy
| Updated at | March 2010 |
Form 20
(Regulation 87)
Signature/thumb impression of the Insured woman.
Employer''s Code No. ...............................................................................
Book .................................
Stamp of the Dispensary
Serial No...........
To
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.
...
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