Form Med 2 - Claim For Maternity Benefit - The National Insurance Board
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2For Official Use Only
The National Insurance Board
I
MPORTANT NOTE: Any person who for the purpose of obtaining benefit under The National
Insurance Act, for himself or for some other person, knowingly makes any false statement or false
Of The Commonwealth of The Bahamas
representations or produces any document, etc. which he knows to be false, shall be liable to a fine
The National Insurance Act, 1972
not exceeding Two Thousand Five Hundred Dollars ($2,500), or to imprisonment for a period not
exceeding twelve (12) months or both.
CLAIM FOR MATERNITY BENEFIT
Section A: Medical Certificate of Expected/Actual Confinement
For Official Use Only
(To be completed by a Registered Medical Practitioner or Certified Midwife.)
1.
In Confidence to:
Mrs.
Ms.
_______________________________________________________________________________
Last Name
First Name
Middle Name(s)
2.
Complete the appropriate type of Confinement below:
Expected Confinement
I certify that I examined you on ________________ and that in my opinion, you may expect to be
dd/mm/yyyy
confined on ________________.
dd/mm/yyyy
Actual Confinement
I certify that I attended you in connection with your confinement on___________________ at
dd/mm/yyyy
______________________________________ and that you were delivered of _____ child(ren).
Name of Medical Facility or Place
I certify that your confinement resulted in the birth of ______ live child(ren).
3.
Doctor:
_______________________________
_____________________________
Name (printed)
Signature
Date: ___________________
Affix Doctor’s Stamp here
dd/mm/yyyy
Note: Claims from Registered Medical Practitioners outside
the Bahamas MUST be accompanied by a business card.
4.
If Certified Midwife, Registration #: _______________________ Certificate Date: ________________
Address: ________________________________________________________
5.
Remarks by Doctor/Midwife: __________________________________________________________
__________________________________________________________________________________
Form Med 2 (Revised 2009)
Form Med 2 (Revised 2009)
Page 1
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