Form XI

[See rule 35 (2)(a) and (c)]

(Notice of claim for maternity benefit and payment thereof under sections 62 and 63)

To

……………….… (name of establishment)

PART I

[See Rule 35 (2)(a)]

Notice

I …………. (name of woman) wife or daughter of…… employed as…… at………(name of

establishment), hereby give notice that I expect to be confined within six weeks next following from

the date of this notice or have given birth to a child on…..(date) and shall be absent from work

from…..(date). I shall not work in any establishment during the period for which I receive maternity

benefit.

2.For the purpose of section 63, I hereby nominate……… (Here enter name and address of the

nominee) to receive maternity benefit and/ or any other amount due to me under the Code in case of

my death.

Signature of an Attester in case Signature or thumb impression of woman

the woman is not able to sign

and affix thumb impression.

Date…………

PART II

[See rule 35 (2)(c)]