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Funeral Home/Cemetery Information

Please enter funeral home/cemetery information.

Funeral Home/Cemetery:*

Contact Name

Contact Phone

Contact Fax

Contact E-mail

Assignment Information

Please enter estimated assignment amount.

Amount Requested

Is The Family Requesting An Advancement Of Funds In Addition To The Funeral Costs?

If yes please contact your ELITE representative to discuss advancement amounts.

Yes/No

Deceased Information

Pleased enter deceased information.

Deceased First Name

Deceased Last Name

Deceased Social Sec

Date of Birth

Date of Death

Deceased Marital Status

Deceased Street Address

Deceased City

Deceased State

Deceased Zip Code

Place of Death (City, State)

Cause Of Death (Select all that apply)

Accident
Homicide
ME/Coroner
Natural
Pending
Suicide

Medical Examiner/ Coroner contact information

Do You Have Final Death Certificate?

Estimated date Final DC will be ready

Deceased being shipped?

Name of FH & contact phone#

Policy Information

Please enter insurance policy information. You may enter up to 4 different insurance companies per deceased on this form.

Insurance Company # 1

1st Insurance Company Name (If not listed, choose OTHER)

Insurance Company Name

Policy Number(s)

Face Amount

Insurance Company # 2

2nd Insurance Company Name (If not listed, choose OTHER)

Insurance Company Name

Policy Number(s) 2

Face Amount 2

Insurance Company # 3

3rd Insurance Company Name (If not listed, choose OTHER)

Insurance Company Name

Policy Number(s) 3

Face Amount 3

Insurance Company # 4

4th Insurance Company Name (If not listed, choose OTHER)

Insurance Company Name

Policy Number(s) 4

Face Amount 4

Group Policy Information

If policy benefit is with employer, enter group policy information.

Is the Deceased the Employee?

Name of Employer

Employer Phone

Employer Contact

Social Security No (SS#) of Employee

Date of Birth of Employee

1st Beneficiary Information

Please enter 1st potential beneficiary information.

Beneficiary Name 1

Bene 1 Relation

Bene 1 Address

Bene 1 City

Bene 1 State

Bene 1 Zip

Bene 1 Date of Birth

Bene 1 Soc

Bene 1 Phone

2nd Beneficiary Information

Please enter 2nd potential beneficiary information.

Beneficiary Name 2

Bene 2 Relation

Bene 2 Address

Bene 2 City

Bene 2 State

Bene 2 Zip

Bene 2 Date of Birth

Bene 2 Soc

Bene 2 Phone

3rd Beneficiary Information

Please enter 3rd potential beneficiary information.

Beneficiary Name 3

Bene 3 Relation

Bene 3 Address

Bene 3 City

Bene 3 State

Bene 3 Zip

Bene 3 Date of Birth

Bene 3 Soc

Bene 3 Phone

4th Beneficiary Information

Please enter 4th potential beneficiary information.

Beneficiary Name 4

Bene 4 Relation

Bene 4 Address

Bene 4 City

Bene 4 State

Bene 4 Zip

Bene 4 Date of Birth

Bene 4 Soc

Bene 4 Phone

5th Beneficiary Information

Please enter 5th potential beneficiary information. If more than 5 beneficiaries contact your ELITE representative.

Beneficiary Name 5

Bene 5 Relation

Bene 5 Address

Bene 5 City

Bene 5 State

Bene 5 Zip

Bene 5 Date of Birth

Bene 5 Soc

Bene 5 Phone

Attach Documents Here!

(e.g., assignment forms, policy pages, Ins co letters, etc.)

Attachment

Drop files here or

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Funeral Home/Cemetery Information

Please enter funeral home/cemetery information.

Assignment Information

Please enter estimated assignment amount.

Is The Family Requesting An Advancement Of Funds In Addition To The Funeral Costs?

If yes please contact your ELITE representative to discuss advancement amounts.

Deceased Information

Pleased enter deceased information.

Policy Information

Please enter insurance policy information. You may enter up to 4 different insurance companies per deceased on this form.

Group Policy Information

If policy benefit is with employer, enter group policy information.

1st Beneficiary Information

Please enter 1st potential beneficiary information.

2nd Beneficiary Information

Please enter 2nd potential beneficiary information.

3rd Beneficiary Information

Please enter 3rd potential beneficiary information.

4th Beneficiary Information

Please enter 4th potential beneficiary information.

5th Beneficiary Information

Please enter 5th potential beneficiary information. If more than 5 beneficiaries contact your ELITE representative.

Attach Documents Here!

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