This ESIC Form 22 is a sample form to be filled out in order to claim funeral expenses from the Employees’ State Insurance Corporation (ESIC). This form is to be filled out by the claimant, who is the legal heir of the deceased employee, in order to receive the funeral expenses. The claimant must provide all the necessary information and documents in order to receive the funeral expenses. The claimant must also provide proof of the deceased employee’s employment and the death certificate of the deceased employee. The claimant must also provide the details of the funeral expenses incurred. This form must be filled out accurately and completely in order to receive the funeral expenses.
ESIC Form 22 Filled Sample to Claim Funeral Expenses
Name of the deceased: John Smith
Date of death: June 15, 2020
Name of claimant: Jane Smith
Address of claimant: 123 Main Street, Anytown, USA
Phone number of claimant: (123) 456-7890
Name of funeral home: Anytown Funeral Home
Address of funeral home: 456 Main Street, Anytown, USA
Phone number of funeral home: (123) 456-7891
Name of cemetery: Anytown Cemetery
Address of cemetery: 789 Main Street, Anytown, USA
Phone number of cemetery: (123) 456-7892
Name of clergy: Reverend John Doe
Address of clergy: 987 Main Street, Anytown, USA
Phone number of clergy: (123) 456-7893
Name of pallbearers:
1. Joe Smith
2. Jane Smith
3. John Doe
4. Jane Doe
5. Bob Smith
6. Mary Smith
Name of other services:
1. Anytown Florist
2. Anytown Limousine Service
3. Anytown Catering
Total amount of funeral expenses: $5,000
I, Jane Smith, hereby certify that the information provided above is true and accurate to the best of my knowledge.
ESIC form 22 is known as funeral expenses claim form, this is used to claim funeral expenses of deceased ESIC member. Under Employee State Insurance Scheme the dependents of deceased ESIC member can get 15000 Rs amount as funeral expenses (W.E.F 1 March 2019). The family members need to claim ESI funeral expenses within 6 months from the date of the death of the insured person. Here can know how to fill ESIC form 22 and also find sample filled ESIC form 22.
How to Fill ESIC Form 22
The following details have to be mentioned on ESIC funeral expenses claim form
- Date of death
- Name of the insured person ( deceased person)
- Relationship name of the deceased person.
- Age of the deceased person.
- ESIC IP number.
- Last worked job details.
- ESIC funeral benefit amount 15000 Rs (maximum).
- Name and details of the claimant.
- Age of the claimant.
- Signature of the claimant.
Also read: ESIC benefits for family members
ESIC Form 22 Filled Sample
The attestation of any of the following persons is required on ESIC form 22
- Officer of revenue or judicial or magisterial departments.
- Municipal commissioner.
- Workmen’s compensation commissioner.
- Head of Gram Panchayat under the official seal of panchayat or MLA / MP.
- Gazetted officer of state / central govt/member of the local committee / regional board
The claimant needs to submit ESIC Pehchan card along with funeral claim form in their regional ESIC branch office.
ESIC Form 22: Filled Sample to Claim Funeral Expenses
The Employees’ State Insurance Corporation (ESIC) Form 22 is a form used to claim funeral expenses for an insured person. This form is used to claim the expenses incurred for the funeral of an insured person who has died due to an accident or illness covered by the Employees’ State Insurance Act, 1948. The form must be filled out and submitted to the ESIC office in the state where the insured person was employed.
Instructions for Filling ESIC Form 22
- The form must be filled out in English or Hindi.
- The form must be filled out in the presence of two witnesses.
- The form must be signed by the claimant and the two witnesses.
- The form must be accompanied by the death certificate of the insured person.
- The form must be accompanied by the original bills and receipts of the funeral expenses.
- The form must be accompanied by the original bills and receipts of the medical expenses incurred for the treatment of the insured person.
- The form must be accompanied by the original bills and receipts of the transportation expenses incurred for the transportation of the body of the insured person.
Sample Filled ESIC Form 22
The following is a sample filled ESIC Form 22 to claim funeral expenses for an insured person who has died due to an accident or illness covered by the Employees’ State Insurance Act, 1948.
Name of the Insured Person: John Doe
Date of Death: 01/01/2020
Name of the Claimant: Jane Doe
Address of the Claimant: 123 Main Street, Anytown, USA
Name of the Witnesses: Joe Smith, Mary Jones
Address of the Witnesses: 456 Main Street, Anytown, USA
Amount Claimed: $1,000
Description of Expenses: Funeral expenses, medical expenses, and transportation expenses.
I, Jane Doe, hereby certify that the above information is true and correct to the best of my knowledge and belief. I further certify that the amount claimed is the actual amount incurred for the funeral expenses, medical expenses, and transportation expenses of the insured person, John Doe.
Signature of Claimant: ___________________________
Signature of Witnesses: ___________________________