Employees' State Insurance (General) Regulations, 1950
FORM 25A : Funeral [Expenses]
Claim arising from the death on ____________ of (insured person)_____ aged ____ years son/wife/daughter of _____________ having Insurance No __________ and last employed as __ son/wife/daughter of _________________ by __________________ (name of last employer).
I_____________ (name of claimant) son/ wife/ daughter of ______ aged ___ years being the eldest surviving member of the family of the deceased insured person, whose particulars are given above declare that I incurred an expenditure of Rs _________ necessary for the funeral of the said deceased person and claim funeral 18[expenses] of the amount of Rs _____
I____________________________ (name of the claimant) son/wife/daughter of _______ aged _____ years declare that the deceased insured person whose particulars are given above did not have a family/was not living with his family at the time of his/her death and that I actually incurred an expenditure of Rs ______________ on the funeral of the deceased insured person and claim funeral 18[expenses] of the amount of Rs ______
Signature or thumb impression of the claimant
**Certified that the declarations made above are true to the best of my knowledge and belief.
(Rubber stamp or seal of the attesting authority)
* Strike out whichever is not applicable.
** This certificate is to be given by (i) an officer of Revenue, Judicial or Magisterial Departments of Government; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (v) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) the employer of the deceased insured person, or (vi) any other authority approved by the appropriate Regional Office.
Notes: 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.
2. In case of a minor, the guardian should sign the claim on behalf of the minor, and add the following words below his signature.
(Name of the minor) through _____________
(Name of the guardian) his/her _____________(relationship)