Form 22 ESIC (Funeral Expense Claim) PDF

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Form 22 ESIC (Funeral Expense Claim)

Form 22 ESIC (Funeral Expense Claim)

Form 22 ESIC is a medical acceptance card issued by the Employees’ State Insurance Corporation (ESIC) in India. It serves as an identity card for insured persons and their family members to avail of medical benefits under the ESIC scheme.

A nominee and, in the absence, the eldest surviving member of the family of the deceased insured person shall submit a claim in the given format to receive expenses incurred towards the funeral of an insured person.

In the case of a minor, the guardian should sign the Claim Form on behalf of the minor and then add the below his/her signature.

How to Fill Form 22 ESIC

Name of the Death of Member

  1. Insurance No.
  2. Employment ID and Code
  3. Nominee Name & Address
  4. And any other details

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