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NATIONAL INSURANCE AND SOCIAL SECURITY ACT, 1969
MEDICAL CERTIFICATE OF EXPECTED
CONFINEMENT
(In Accordance with National Insurance and Social Security (Medical Certification) Regulations No. 36 of 1969)
(To be given by a Registered Medical Practitioner or Registered Midwife not earlier than the beginning of the ninth week* before the week* containing the day of expected confinement)
To……………………………………………..……………………………………………
I certify that I examined you on the under mentioned date and that in my opinion you may expect to be confined in the week* which will include the ……………….day of ……………………………………………...20………………
(Here insert the expected date of confinement)
Signature …………………………………..
(If Registered Midwife, add
register number……………………………
or address and date of
Qualification)……………………………….
Date of Examination ……………………..
Date of Signing …………………………...
Any other remarks by Doctor or Midwife ……………………………..................
………………………………………………………………………………………..…….
*The week referred to is a contribution week, i.e. one which begins on a Monday.

FORM Med. 3

Research & Planning Dept. (Revised June 2010)

NATIONAL INSURANCE AND SOCIAL SECURITY ACT, 1969
MEDICAL CERTIFICATE OF EXPECTED
CONFINEMENT
(In Accordance with National Insurance and Social Security (Medical Certification) Regulations No. 36 of 1969)
(To be given by a Registered Medical Practitioner or Registered Midwife not earlier than the beginning of the ninth week* before the week* containing the day of expected confinement)
To……………………………………………..……………………………………………
I certify that I examined you on the under mentioned date and that in my opinion you may expect to be confined in the week* which will include the ……………….day of ……………………………………………...20………………
(Here insert the expected date of confinement)
Signature …………………………………..
(If Registered Midwife, add
register number……………………………
or address and date of
Qualification)……………………………….
Date of Examination ……………………..
Date of Signing …………………………...
Any other remarks by Doctor or Midwife ……………………………..................
………………………………………………………………………………………..…….
*The week referred to is a contribution week, i.e. one which begins on a Monday.

FORM Med. 3

Research & Planning Dept. (Revised June 2010)

NATIONAL INSURANCE AND SOCIAL SECURITY ACT, 1969
CLAIM FOR MATERNITY BENEFIT
I hereby apply for Maternity Benefit under the National Insurance and Social Security Act, 1969, and furnish a *Certificate of Confinement/Certificate of Expected Confinement at back hereof, and the following particulars:-
My full name is……………………………………………………………………………………...…
(Block Letters)
My address is ………………………………………………………………………………….……...
My National Insurance Number is
I am/was employed by………………………..……………………………………………………..
as an …………………………………………………………………………………………………...
I last worked there on ……………………………………………………………………………….
*I do not expect to receive any wages or salary from my employer during my absence from work./ I will be given ………………..weeks leave from ……………. 20……… to ……………… 20………… during which period I will be paid ………………………per week/month.
………..…………………………………..
Signature of Claimant
…………………………………………...
Date
(If unable to write mark X and have it witnessed)
Witness to Mark ……………………………..................
Name
………………………………………….
Occupation
…………………………………………..
Address
…………………………………………..
Date
Note: 1. Maternity Benefit cannot be paid for any period earlier than six weeks before the week of expected confinement as certified by the Medical Practitioner or Registered Midwife, nor can it be paid for any period before the date of your claim.
2. Maternity Benefit will be reduced if, together with any wages paid by your employer for maternity leave granted by him, it exceeds your average weekly wage for the last thirteen weeks before the week in which your claim is made.
3. Maternity Benefit will not be paid for any period during which you are engaged in paid employment.
*Delete where inapplicable
FORM MB2

NATIONAL INSURANCE AND SOCIAL SECURITY ACT, 1969
CLAIM FOR MATERNITY BENEFIT
I hereby apply for Maternity Benefit under the National Insurance and Social Security Act, 1969, and furnish a *Certificate of Confinement/Certificate of Expected Confinement at back hereof, and the following particulars:-
My full name is……………………………………………………………………………………...…
(Block Letters)
My address is ………………………………………………………………………………….…….
My National Insurance Number is
I am/was employed by……………………………………………………………………………...
as an ………………………………………………………………………………………………….
I last worked there on ……………………………………………………………………………...
*I do not expect to receive any wages or salary from my employer during my absence from work./ I will be given ………………..weeks leave from ……………. 20……… to ……………… 20………… during which period I will be paid ………………………per week/month.
………..…………………………………..
Signature of Claimant
…………………………………………...
Date
(If unable to write mark X and have it witnessed)
Witness to Mark ……………………………..................
Name
………………………………………….
Occupation
…………………………………………..
Address
…………………………………………..
Date
Note: 1. Maternity Benefit cannot be paid for any period earlier than six weeks before the week of expected confinement as certified by the Medical Practitioner or
Registered Midwife, nor can it be paid for any period before the date of your claim.
2. Maternity Benefit will be reduced if, together with any wages paid by your employer for maternity leave granted by him, it exceeds your average weekly wage for the last thirteen weeks before the week in which your claim is made.
3. Maternity Benefit will not be paid for any period during which you are engaged in paid employment.
*Delete where inapplicable
FORM MB2