CLAIM FORM

Maternity Benefit

CLAIM FORM

I ………… Insurance No. …………………………wife of/daughter of ………… here claim maternity benefit with effect from the ………… day of ………… 19……… I hereby declare that I have ceased/shall cease to work for remuneration with effect from that date.

Present/last employer …………………………………………………….

Department, shift and occupation …………………………………….

Present address ………………………………………………………………

Date ……………

Signature or thumb impression