ESIC Form 22 Filled Sample to Claim Funeral Expenses

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.

Download 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.