Confinement Certificate/maternity Grant Application Form Page 2
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1
2EMPLOYER’S CERTIFICATE
IMPORTANT: Only complete for an insured woman who is not in receipt of weekly maternity benefits, or for
an insured man who is claiming on behalf of his spouse.
I certify that the insured claimant referred to overleaf
Surname _________________________________________
SS# ______________________________________
Name ___________________________________________
Address ___________________________________
Date of Birth _______________________________ has been employed with this organization as a/an ____________
____________________________ from _______________________ 19_____, to _____________________ 20 ____.
State occupation
During the qualifying period *(a) ________________________ to *(b) ______________________ the insured person
was paid monthly/weekly wages as stated below. (See *(a) & *(b) below for guidelines.)
Date
Wk Amount
Date
Wk Amount
Date
Wk Amount
Date
Wk Amount
1
9
17
25
2
10
18
26
3
11
19
27
4
12
20
28
5
13
21
29
6
14
22
30
7
15
23
31
8
16
24
32
Last Day insured person worked ________________________________
I certify that the above statements are true to the best of my knowledge and that the information corresponds with my
employee records.
Signed _____________________________________________
Tel.# ____________________________________
Name of Employer ___________________________________
Employer’s Stamp & Date ___________________
Address of Employer _________________________________
*(a) Refers to the date that is 26 weeks or 6 months in the last 52 weeks prior to the date of confinement
*(b) Refers to the date of confinement.
IMPORTANT: Read before submitting claim.
A claim after confinement must be submitted not later than 15 days after the date of confinement. Claims not submitted
within the prescribed time must be accompanied by a written excuse explaining the reasons for lateness.
Failure to comply may result in loss of benefits.
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