FORM 22 FENERAL EXPENSES CLAIM FORM EMPLO YEES' ST A TE INSURANCE CORPORA TION (R egulation 95-E) Claim arising out of death on .................. of ................. s/w/d of .................. aged ..................... years, having Insurance No. .............. and last employed as ................. by M/s. ................... Code No. .................... I ....................................... s/w/d of .......................................... aged ........................ years declare : **(i) that I am the eldest sur viving member of the family of the deceased Insured P erson, whose particulars are fur nished here-in-above, and that I actually incur red an e xpenditure of Rs. .................... (R upees .................. only) necessar y for the funeral of the said deceased person. or **(ii) that the deceased Insured P erson, whose particulars are fur nished there-in-above, did not have a family / was not living with his family at the time of his / her death and that I actually incur red an e xpenditure of Rs. .................... (Rupees ...............only) on the funeral of the deceased Insured P erson. A ccordingly , I do hereby claim funeral e xpenses for the amount of Rs. .................................... (R upees .............................only) Date : Name in Block Letters ................................................................................... Signature / Thumb-impression of the Claimant A TTESA TION *** Certified that the declarations, as made here-in-above, are tr ue to the best of my knowledge and belief . Name in Block Letters and R ubber Stamp Signature ................................... or Seal of the A ttesting A uthority Designation ............................... Date ............................................. *Delete either (i) or (ii), which may not be applicable in the case. **This certificate is to given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner , or (iii) a W orkmen's Compensation Commissioner; or (iv) the Head of Gram P anchayat under the official seal of the P anchayat, or M.L.A./M.P .; or (v) A Gazetted Officer of the Central/State Govt./Member of the Local Committee / Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concer ned. Important : Any person who mak es a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a ter m which may e xtend up to six months or with a fine up to Rs. 2,000/- or with both.] Note : In the case of a minor , the guardian should sign the claim for m on bahalf of the minor and then add the following below his/her signature: ........................................ (Name of the Minor) Through ..................... (Name of the Guardian) his/her ............................ (Relationship with the Minor)
