Elite Funeral Funding

P.O. Box 25128

Phone: 954-945-3114

Tamarac, FL 33320

Email: newclaims@elitefuneralfunding.com

Fax: 954-233-5024

NEW CLAIM INFORMATION FORM

Funeral Home:

Ph:

Deceased:

Date of Death:

Assign amt:

SS#

Date of Birth:

# of Surviving Children:

Cause of Death: (check one)

Natural

Accident

Homicide

Suicide

Pending DC (coroner case)

Marital Status: (check one)

Married

Divorced

Never Married

Widowed

Srvc Date:

Ins.Co.		Ph# (if available):
Policy Number(s)
Issue Dates
Face Amounts
Beneficiary(ies)
Do you have the policy?	Yes No	Yes No	Yes No
Has the above Ins.Co. been notified?	Yes No

Ins.Co.
Ph# (if available):
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Has the above Ins.Co. been notified?	Yes No

Ins.Co.		Ph# (if available):
Policy Number(s)
Issue Dates
Face Amounts
Beneficiary(ies)
Do you have the policy?	Yes No	Yes No	Yes No
Has the above Ins.Co. been notified?	Yes No

Ins.Co.
Ph# (if available):
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Policy Number
Issue Date
Face Amount
Beneficiary(ies)
Do you have the policy?	Yes No
Has the above Ins.Co. been notified?	Yes No

If coverage is through an employer (GROUP CLAIM), please provide Employer contact information.

EMPLOYER:

Contact Name:

Employer Phone:

Is the deceased the EMPLOYEE? Yes No