Esic death claim form 2026

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The document is a claim form for funeral expenses (FORM 25 A) that allows the eldest surviving family member of a deceased insured person to claim reimbursement for funeral costs. It requires details about the deceased, the claimant, and the incurred expenses, along with a declaration of truthfulness. The form must be certified by an authorized official and includes notes on legal implications for false statements.

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Click ‘Get Form’ to open the esic death claim form in the editor.
Begin by entering the date of death and the details of the insured person, including their name, age, and insurance number. This information is crucial for processing your claim.
Indicate your relationship to the deceased (son, wife, daughter) and provide your own details as the claimant, including your name and age.
In the expenditure section, clearly state the amount incurred for funeral expenses. Ensure that this figure matches any receipts or documentation you have.
If applicable, confirm whether the deceased was living with their family at the time of death. This may affect eligibility for certain claims.
Sign or provide a thumb impression as required. Make sure to include your address for correspondence regarding your claim.
Finally, ensure that an authorized individual certifies your declaration by signing and stamping it appropriately.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the use of Form 37 ESIC?

What is the purpose of form 37 esic? The purpose of Form 37 ESIC is to ensure that all eligible employees are registered under the ESIC scheme, enabling them to access medical and social security benefits.

How do I claim ESIC reimbursement?

Heres the process: Get a medical certificate from an ESIC-recognised doctor or hospital. Submit it to your employer along with the necessary leave application. Employer forwards the claim online through the esic claim process. Once approved, the payment is transferred directly to your bank account.

What is the benefit period for ESIC?

There are two contribution periods each of six months duration and two corresponding benefit periods also of six months duration as under.

How to fill an ESIC funeral expenses form?

The following information must be included on the ESIC funeral expense claim form: Name of the insured person ( deceased person) Relationship name of the deceased person. Date of death. Age of the deceased person. ESIC IP number. ESIC funeral benefit amount 15000 Rs (maximum). Name and details of the claimant.

How to claim death benefit from ESIC?

Form-15 claim for dependent benefit by ESIC You can find the Form-15 claim for permanent disablement benefit provided by the Employees State Insurance Corporation (ESIC), Ministry of Labour and Employment, Government of India. Users must read the form and fill up as per the given instructions.

esic form 22 funeral expenses claim filled sample

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What are the benefits of ESIC after death?

For life to the widow or until her re-marriage, and to dependant son till the age of 25 years, till marriage of daughter and to dependant parents etc. Subject to conditions. 90% of the average daily wages approx. 90% of average daily wages shareable in fixed proportion among all dependants.

How to fill a death claim form?

Dear Sir, Re: Deceased Account. Late Shri/Smt .. Account No (s) I/We advise the demise of Shri/Smt. on. . He/She holds the above account(s) at your branch. Annexure-II. ESTATE CLAIM FORM. UNION BANK OF INDIA.