Introduction

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.

Signature: ___________________________

Date: ___________________________

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: ___________________________

___________________________