FORM
8
(CONFIDENTIAL)
SPECIAL
INTERMEDIATE CERTIFICATER
EMPLOYEES
STATE INSURANCE CORPORATION
(Regulations
61 & 89-B)
Book No.
..
S. No.
..
Stamp of Dispensary
Signature or Thumb Impression of the IP
Date of First
Certificate of spell of
Employers Code No.
Sickness or
Disablement
Branch
Office
To
..s/w/d/
..Ins.
No.
|
Any other
remarks by the Medical Officer
..
.
..
..
..
.. |
Certified
that I have examined you
. Today and that in my opinion you have
continued to need medical treatment and have remained in capable to work upto
and including this day by reason of
.further certify that by
judging your present condition it is found that your sickness is of such a
character that it will be unnecessary to see you for the purpose of treatment
and will remain incapable to work at least upto the end of
. Weeks
from this date
.. I propose to
issue certificates in this form at the interval stated above so long as your
condition does not require more frequent attendance.
In my opinion you should now/need not be referred to a Medical Board
to determine if you are permanently disabled. |
Date
..
Signature
..
Ins. Medical
Officer with Rubber Stamp
Name in Block
letters