Download ESIC FORM 22
Download ESIC FORM 22 FUNERAL EXPENSES CLAIM FORM EMPLOYEES’ STATE INSURANCE CORPORATION
As per Regulation 95-E. Submission of claim for funeral [expenses]
(1) A claim to funeral [expenses] shall be submitted to the appropriate [branch office] by post or otherwise in [Form 22] by the claimant entitled under the Act and in case of a minor, by his guardian, and such claim shall be supported by documents proving—
(i) the death of the deceased person,
(ii) that the person claiming is the eldest surviving member of the family of the deceased insured person and incurred the expenditure necessary for the funeral of the deceased
(iii) in case the claimant is other than the eldest surviving member of the family—
(a) that the deceased insured person did not have a family or that the deceased insured person was not living with his family at the time of his death; and
(b) that the claimant actually incurred the expenditure claimed on the funeral of the deceased insured person: PROVIDED that where the appropriate office is satisfied about the boua fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with.
(2) The following may be accepted as proof for purposes of clauses (ii) and (iii) of sub-regulation
(1) of this regulation—
A declaration of the claimant duly countersigned by—
(i) an officer of the Revenue, Judicial or Magisterial Departments of Government; or
(ii) a Municipal Commissioner; or
(iii) a Workmen’s Compensation Commissioner; or
(iv) the Head of Gram Panchayat under the official seal of the Panchayat; or
(v) the employers of the deceased insured person; or
(vi) any other evidence or declaration acceptable to the appropriate office in the
circumstances of a particular case.
