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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
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
Never Married
Married
Separated
Divorced
Widowed
Deceased Street Address
Deceased City
Deceased State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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?
Yes
No
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)
AAA
AARP (NY Life)
AETNA (group)
AFLAC
Afro- American Life
American Health & Life- Allstate
Americo (preneed)
American General Life
ALFA
Allstate (IAS)
Allstate (Lincoln Benefit)
Allstate (Sears)
Allstate Life Insurance
American Amicable
American Benefit
American Family (Wisconsin)
American Home World
American Income Life
American Memorial
American National Life
American Pioneer
American United Life - AUL
Americo
Anthem
Assurant (Individual)
Assurant Group
Assurant Preneed
Assurity
Athene
Athene (Aviva)
Auto Owners
AXA Equitable
Baltimore Life
BrightHouse Life (Metlife)
Bankers Fideltiy
Bankers Life and Casualty
Booker T Washington
Boston Mutual
Capital Security Life
Career
Central Security
Chesapeake Life
CIGNA (Group )
Cincinnati Insurance Co.
Citizen National
Colonial Life & Accident
Columbian Mutual (Binghamton, NY)
Colonial Penn
Colorado Bankers
Columbian Financial (Unity Mutual)
Combined
Continental General
Cotton States
CUNA
Dearborn National (Group)
Delta
Directors Life
Employee Life
Equitable
Family Life
Family Service Life
Farm Bureau
Farmers
Farmers New World
FDLIC
FEGLI (Retired)
FEGLI – Active (provide employer contact)
Fidelity & Guaranty
Foresters
Forethought Life (Global Atlantic)
Genworth
Gerber
Globe Life
GPM (Govt Personnel Mutual)
Grange
Great American
Great West (Group)
Great West (individual)
Guardian Life
Hartford (Hartford Group)
Hartford Life
Homesteaders
Horace Mann
Humana Inc (Kanawha Life)
Indiana Farm Bureau
ING
Investors Heritage
Jackson National
John Hancock
Kansas City Life
Kemper- United Ins Co
Kilpatrick
Knights of Columbus
Landmark
Liberty Bankers Life
Liberty National Life
Lincoln Financial Group (Group)
Lincoln Financial Group (Individual)
Lincoln Heritage
Lincoln Memorial Life
Madison National Life
Mass Mutual
Medico
Metlife (Group)
Metropolitan Life (individual)
Monumental / Transamerica life
Midland National
Minnesota Life (Group)
Modern Woodman Of American
Monumental Life
Monumental Life (Valley Forge)
MONY
Motorist Life
Mutual Of Omaha
National Family Life
National Guardian Life (NGL)
National Securtiy
National States
National Western
Nationwide
New York Life
North American Life
North Carolina Mutual
Northwestern Mutual
Occidental Life
Old American
OM Financial
Oxford Life
Pennsylvania Life
Physicians Life
Pioneer Security
Presidential Life
Primerica
Principal Financial (Group)
Prudential Life
Prudential Life (Group)
Pyramid Life
Rabenhorst
Reassure America
Reassure - Preneed
Reliance Standard
Reliable Life (United/Kemper)
Reliable Life (Louisiana)
Reliastar Life
Royal Neighbors of America
Sagicor
SBLI
Security Life
Security National
Security Plan
Senior Life
Settlers Life
SFLIC
Shenandoah Life
Southern Farm Bureau
Southland
Standard Life
State Farm
State Mutual
Stonebridge (Valley Forge)
Stonebridge / JCPenny Life
Sun Life Financial
SunLife Financial (Group)
Symetra
Tennessee Farm Bureau
Texas Service Life
Transamerica
Transamerica (Worksite)
Trustmark
Ullico
Unicare
Union Bankers
United Heritage
Unity Financial
Unity Life
Universal Guaranty
Universal Guaranty (American Capital)
UNUM
USAA Life
Wabash Life
Washington National
Western & Southern Life
Western American Life
Western Reserve Life
William Penn Life
Woodman Of The World
World Service Life
Zurich- American Life
Zurich-Kemper Life
Other
Insurance Company Name
Policy Number(s)
Face Amount
Insurance Company # 2
2nd Insurance Company Name (If not listed, choose OTHER)
AAA
AARP (NY Life)
AETNA (group)
AFLAC
Afro- American Life
American Health & Life- Allstate
Americo (preneed)
American General Life
ALFA
Allstate (IAS)
Allstate (Lincoln Benefit)
Allstate (Sears)
Allstate Life Insurance
American Amicable
American Benefit
American Family (Wisconsin)
American Home World
American Income Life
American Memorial
American National Life
American Pioneer
American United Life - AUL
Americo
Anthem
Assurant (Individual)
Assurant Group
Assurant Preneed
Assurity
Athene
Athene (Aviva)
Auto Owners
AXA Equitable
Baltimore Life
BrightHouse Life (Metlife)
Bankers Fideltiy
Bankers Life and Casualty
Booker T Washington
Boston Mutual
Capital Security Life
Career
Central Security
Chesapeake Life
CIGNA (Group )
Cincinnati Insurance Co.
Citizen National
Colonial Life & Accident
Columbian Mutual (Binghamton, NY)
Colonial Penn
Colorado Bankers
Columbian Financial (Unity Mutual)
Combined
Continental General
Cotton States
CUNA
Dearborn National (Group)
Delta
Directors Life
Employee Life
Equitable
Family Life
Family Service Life
Farm Bureau
Farmers
Farmers New World
FDLIC
FEGLI (Retired)
FEGLI – Active (provide employer contact)
Fidelity & Guaranty
Foresters
Forethought Life (Global Atlantic)
Genworth
Gerber
Globe Life
GPM (Govt Personnel Mutual)
Grange
Great American
Great West (Group)
Great West (individual)
Guardian Life
Hartford (Hartford Group)
Hartford Life
Homesteaders
Horace Mann
Humana Inc (Kanawha Life)
Indiana Farm Bureau
ING
Investors Heritage
Jackson National
John Hancock
Kansas City Life
Kemper- United Ins Co
Kilpatrick
Knights of Columbus
Landmark
Liberty Bankers Life
Liberty National Life
Lincoln Financial Group (Group)
Lincoln Financial Group (Individual)
Lincoln Heritage
Lincoln Memorial Life
Madison National Life
Mass Mutual
Medico
Metlife (Group)
Metropolitan Life (individual)
Monumental / Transamerica life
Midland National
Minnesota Life (Group)
Modern Woodman Of American
Monumental Life
Monumental Life (Valley Forge)
MONY
Motorist Life
Mutual Of Omaha
National Family Life
National Guardian Life (NGL)
National Securtiy
National States
National Western
Nationwide
New York Life
North American Life
North Carolina Mutual
Northwestern Mutual
Occidental Life
Old American
OM Financial
Oxford Life
Pennsylvania Life
Physicians Life
Pioneer Security
Presidential Life
Primerica
Principal Financial (Group)
Prudential Life
Prudential Life (Group)
Pyramid Life
Rabenhorst
Reassure America
Reassure - Preneed
Reliance Standard
Reliable Life (United/Kemper)
Reliable Life (Louisiana)
Reliastar Life
Royal Neighbors of America
Sagicor
SBLI
Security Life
Security National
Security Plan
Senior Life
Settlers Life
SFLIC
Shenandoah Life
Southern Farm Bureau
Southland
Standard Life
State Farm
State Mutual
Stonebridge (Valley Forge)
Stonebridge / JCPenny Life
Sun Life Financial
SunLife Financial (Group)
Symetra
Tennessee Farm Bureau
Texas Service Life
Transamerica
Transamerica (Worksite)
Trustmark
Ullico
Unicare
Union Bankers
United Heritage
Unity Financial
Unity Life
Universal Guaranty
Universal Guaranty (American Capital)
UNUM
USAA Life
Wabash Life
Washington National
Western & Southern Life
Western American Life
Western Reserve Life
William Penn Life
Woodman Of The World
World Service Life
Zurich- American Life
Zurich-Kemper Life
Other
Insurance Company Name
Policy Number(s) 2
Face Amount 2
Insurance Company # 3
3rd Insurance Company Name (If not listed, choose OTHER)
AAA
AARP (NY Life)
AETNA (group)
AFLAC
Afro- American Life
American Health & Life- Allstate
Americo (preneed)
American General Life
ALFA
Allstate (IAS)
Allstate (Lincoln Benefit)
Allstate (Sears)
Allstate Life Insurance
American Amicable
American Benefit
American Family (Wisconsin)
American Home World
American Income Life
American Memorial
American National Life
American Pioneer
American United Life - AUL
Americo
Anthem
Assurant (Individual)
Assurant Group
Assurant Preneed
Assurity
Athene
Athene (Aviva)
Auto Owners
AXA Equitable
Baltimore Life
BrightHouse Life (Metlife)
Bankers Fideltiy
Bankers Life and Casualty
Booker T Washington
Boston Mutual
Capital Security Life
Career
Central Security
Chesapeake Life
CIGNA (Group )
Cincinnati Insurance Co.
Citizen National
Colonial Life & Accident
Columbian Mutual (Binghamton, NY)
Colonial Penn
Colorado Bankers
Columbian Financial (Unity Mutual)
Combined
Continental General
Cotton States
CUNA
Dearborn National (Group)
Delta
Directors Life
Employee Life
Equitable
Family Life
Family Service Life
Farm Bureau
Farmers
Farmers New World
FDLIC
FEGLI (Retired)
FEGLI – Active (provide employer contact)
Fidelity & Guaranty
Foresters
Forethought Life (Global Atlantic)
Genworth
Gerber
Globe Life
GPM (Govt Personnel Mutual)
Grange
Great American
Great West (Group)
Great West (individual)
Guardian Life
Hartford (Hartford Group)
Hartford Life
Homesteaders
Horace Mann
Humana Inc (Kanawha Life)
Indiana Farm Bureau
ING
Investors Heritage
Jackson National
John Hancock
Kansas City Life
Kemper- United Ins Co
Kilpatrick
Knights of Columbus
Landmark
Liberty Bankers Life
Liberty National Life
Lincoln Financial Group (Group)
Lincoln Financial Group (Individual)
Lincoln Heritage
Lincoln Memorial Life
Madison National Life
Mass Mutual
Medico
Metlife (Group)
Metropolitan Life (individual)
Monumental / Transamerica life
Midland National
Minnesota Life (Group)
Modern Woodman Of American
Monumental Life
Monumental Life (Valley Forge)
MONY
Motorist Life
Mutual Of Omaha
National Family Life
National Guardian Life (NGL)
National Securtiy
National States
National Western
Nationwide
New York Life
North American Life
North Carolina Mutual
Northwestern Mutual
Occidental Life
Old American
OM Financial
Oxford Life
Pennsylvania Life
Physicians Life
Pioneer Security
Presidential Life
Primerica
Principal Financial (Group)
Prudential Life
Prudential Life (Group)
Pyramid Life
Rabenhorst
Reassure America
Reassure - Preneed
Reliance Standard
Reliable Life (United/Kemper)
Reliable Life (Louisiana)
Reliastar Life
Royal Neighbors of America
Sagicor
SBLI
Security Life
Security National
Security Plan
Senior Life
Settlers Life
SFLIC
Shenandoah Life
Southern Farm Bureau
Southland
Standard Life
State Farm
State Mutual
Stonebridge (Valley Forge)
Stonebridge / JCPenny Life
Sun Life Financial
SunLife Financial (Group)
Symetra
Tennessee Farm Bureau
Texas Service Life
Transamerica
Transamerica (Worksite)
Trustmark
Ullico
Unicare
Union Bankers
United Heritage
Unity Financial
Unity Life
Universal Guaranty
Universal Guaranty (American Capital)
UNUM
USAA Life
Wabash Life
Washington National
Western & Southern Life
Western American Life
Western Reserve Life
William Penn Life
Woodman Of The World
World Service Life
Zurich- American Life
Zurich-Kemper Life
Other
Insurance Company Name
Policy Number(s) 3
Face Amount 3
Insurance Company # 4
4th Insurance Company Name (If not listed, choose OTHER)
AAA
AARP (NY Life)
AETNA (group)
AFLAC
Afro- American Life
American Health & Life- Allstate
Americo (preneed)
American General Life
ALFA
Allstate (IAS)
Allstate (Lincoln Benefit)
Allstate (Sears)
Allstate Life Insurance
American Amicable
American Benefit
American Family (Wisconsin)
American Home World
American Income Life
American Memorial
American National Life
American Pioneer
American United Life - AUL
Americo
Anthem
Assurant (Individual)
Assurant Group
Assurant Preneed
Assurity
Athene
Athene (Aviva)
Auto Owners
AXA Equitable
Baltimore Life
BrightHouse Life (Metlife)
Bankers Fideltiy
Bankers Life and Casualty
Booker T Washington
Boston Mutual
Capital Security Life
Career
Central Security
Chesapeake Life
CIGNA (Group )
Cincinnati Insurance Co.
Citizen National
Colonial Life & Accident
Columbian Mutual (Binghamton, NY)
Colonial Penn
Colorado Bankers
Columbian Financial (Unity Mutual)
Combined
Continental General
Cotton States
CUNA
Dearborn National (Group)
Delta
Directors Life
Employee Life
Equitable
Family Life
Family Service Life
Farm Bureau
Farmers
Farmers New World
FDLIC
FEGLI (Retired)
FEGLI – Active (provide employer contact)
Fidelity & Guaranty
Foresters
Forethought Life (Global Atlantic)
Genworth
Gerber
Globe Life
GPM (Govt Personnel Mutual)
Grange
Great American
Great West (Group)
Great West (individual)
Guardian Life
Hartford (Hartford Group)
Hartford Life
Homesteaders
Horace Mann
Humana Inc (Kanawha Life)
Indiana Farm Bureau
ING
Investors Heritage
Jackson National
John Hancock
Kansas City Life
Kemper- United Ins Co
Kilpatrick
Knights of Columbus
Landmark
Liberty Bankers Life
Liberty National Life
Lincoln Financial Group (Group)
Lincoln Financial Group (Individual)
Lincoln Heritage
Lincoln Memorial Life
Madison National Life
Mass Mutual
Medico
Metlife (Group)
Metropolitan Life (individual)
Monumental / Transamerica life
Midland National
Minnesota Life (Group)
Modern Woodman Of American
Monumental Life
Monumental Life (Valley Forge)
MONY
Motorist Life
Mutual Of Omaha
National Family Life
National Guardian Life (NGL)
National Securtiy
National States
National Western
Nationwide
New York Life
North American Life
North Carolina Mutual
Northwestern Mutual
Occidental Life
Old American
OM Financial
Oxford Life
Pennsylvania Life
Physicians Life
Pioneer Security
Presidential Life
Primerica
Principal Financial (Group)
Prudential Life
Prudential Life (Group)
Pyramid Life
Rabenhorst
Reassure America
Reassure - Preneed
Reliance Standard
Reliable Life (United/Kemper)
Reliable Life (Louisiana)
Reliastar Life
Royal Neighbors of America
Sagicor
SBLI
Security Life
Security National
Security Plan
Senior Life
Settlers Life
SFLIC
Shenandoah Life
Southern Farm Bureau
Southland
Standard Life
State Farm
State Mutual
Stonebridge (Valley Forge)
Stonebridge / JCPenny Life
Sun Life Financial
SunLife Financial (Group)
Symetra
Tennessee Farm Bureau
Texas Service Life
Transamerica
Transamerica (Worksite)
Trustmark
Ullico
Unicare
Union Bankers
United Heritage
Unity Financial
Unity Life
Universal Guaranty
Universal Guaranty (American Capital)
UNUM
USAA Life
Wabash Life
Washington National
Western & Southern Life
Western American Life
Western Reserve Life
William Penn Life
Woodman Of The World
World Service Life
Zurich- American Life
Zurich-Kemper Life
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?
Yes
No
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
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Bene 5 Zip
Bene 5 Date of Birth
Bene 5 Soc
Bene 5 Phone
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