Form 22 ESIC PDF

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Form 22 ESIC

This is an Application Form for Funeral Expenses Claim Form issued by the Employee’s State Insurance Corporation (ESIC), Ministry of Labour and Employment, Government of India and this form can be download from the official website of ESIC i.e http://servagya.com or it can be directly downloaded in PDF format from the link given below.

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 following below his/her signature.

Details to be Mention in Form 22 ESIC

  • Name of the Death of Member
  • Insurance No.
  • Employment ID and Code
  • Nominee Name & Address
  • And any other details

 

Form 22 ESIC PDF Download Link

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