Fillable AZ GA4 TRADITIONAL BURIAL LOCKED

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AZ GA4 TRADITIONAL BURIAL LOCKED

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A4200-01-AZ
WHITE COPY – Company YELLOW COPY – Agent PINK COPY – Family
Page 1 of 2
(06-17) (GEN) (XP)
STATEMENT OF GOODS AND SERVICES SELECTED
GUARANTEED FUNERAL GOODS AND SERVICES
Our Service
Disposition
Burial Cremation Other
Arrangement and Professional
$
Casket
Urn
$
Embalming
$
Manufacturer
If you have selected a funeral that may require embalming, such as a funeral
with viewing, you may have to pay for embalming. You do not have to pay for
embalming you did not approve if you selected arrangements such as a direct
cremation or immediate burial. If we charge for embalming, we will explain
why below:
Model # and Name
Exterior Material and Color
Interior Material and Color
Your cemetery requires an outer container for burial: Yes No
Other Preparations
$
Outer Burial/Alternative Container
$
Use of Facilities/Staff/Equipment for:
Manufacturer
Visitation _____ Days @ $ _________ / day
$
Model # and Name
Funeral/Memorial Service
$
Material
Graveside Service
$
Transfer of Deceased ( _______ miles)
$
Other (specify)
$
Family Car(s) # _____ @ $ ___________ / each
$
Other (specify)
$
Hearse
$
Other (specify)
$
Escort
$
Total Guaranteed Funeral Price
$
Forwarding/Receiving Remains
$
Required Purchase: Charges are only for those items that you selected
or that are required. If we are required by law or by a cemetery or
crematory to use any items, we will explain the reasons in writing below.
Any legal, cemetery or crematory requirement that we represented to you
as compelling the purchase of any goods and services called for by this
Agreement is identified and described below:
Other Services/Facilities/Equipment/Service Vehicle
$
Cremation Fee
$
Other (specify)
$
Other (specify)
$
Total Services
$
NON-GUARANTEED CASH ADVANCE ITEMS (ESTIMATED)
I understand the cost of these items are estimates and not guaranteed by the funeral home.
Additional funds may be required at time of service.
(Purchaser’s Initials)
Obituary Expense
$
Grave Opening and Closing
$
Death Certificate (Qty _____ )
$
Vault Company Service Charge
$
Flowers
$
Marker Inscription Fee
$
Clergy Honorarium
$
Other (specify)
$
Music
$
Other (specify)
$
Cosmetology Services
$
Other (specify)
$
Crematory Service Charge/Cremation Permit
$
Other (specify)
$
Sales Tax
$
We charge you for our service in obtaining
those items marked with an “X.”
Total Allowance for Cash Advance Items
$
Total Guaranteed and Non-Guaranteed Funeral Price
$
(if applicable) The sale evidenced by this Agreement was solicited at a location other than Funeral Firm’s place of business.
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the
accompanying notice of cancellation form for an explanation of this right.
Funeral Recipient (Insured)
Funeral Recipient’s Signature
Date (mm/dd/yyyy)
Purchaser (if other than Funeral Recipient)
Purchaser’s Signature (if other than Funeral Recipient)
Date (mm/dd/yyyy)
Funeral Firm Name
Funeral Firm Representative’s Signature
Date (mm/dd/yyyy)
Funeral Firm Street Address
City
State
Zip Code
Telephone Number
1395.00
695.00
1
395
395.00
50
695.00
695.00
3875.00
1595.00
20 GUAGE N/S
995.00
CONCRETE
6465.00
240.87
240.87
6705.87
Preston Funeral Home
3800 S. Central Ave.
Phoenix
AZ
85040
602-304-0083
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A4200-01-AZ
WHITE COPY – Company YELLOW COPY – Agent PINK COPY – Family
Page 2 of 2
(06-17)
FUNERAL PLANNING AGREEMENT (“Agreement”)
Performance Guarantee
The Funeral Firm will provide the planned funeral as shown on the accompanying statement of funeral goods and services unless factors beyond its
control prevent it from doing so. The Funeral Firm will furnish the brands or makes of merchandise shown or, if unavailable, merchandise of equivalent
quality. If the Funeral Firm is unable to provide the planned funeral, another funeral firm may agree to provide the goods and services.
Price Guarantee
The Funeral Firm will accept the Forethought Life Insurance Company life insurance or annuity contract (“Insurance Contract”) death benefit as the full
payment for the Guaranteed Funeral Goods and Services, even if the retail price for those items at the time of need is greater than the death benefit.
The Funeral Firm is not entitled to receive the death benefits purchased to fund Non-Guaranteed Cash Advance Items to cover the retail price of
guaranteed items.
If the at-need retail price is less than the death benefit, the excess will be divided between the Funeral Firm and the beneficiary named in the Insurance
Contract, the Funeral Firm being entitled to the percentage of the preneed funeral price attributable to Guaranteed Funeral Goods and Services, the
beneficiary entitled to the percentage attributable to Cash Advance Items. Accordingly, the proceeds paid to the Funeral Firm may be greater than
the retail price of the provided funeral. The beneficiary may authorize payment of its percentage of the excess for additional items not listed in this
Agreement.
The date from which this guarantee is effective will be determined by the type of Insurance Contract you purchase.
1. If you purchase an Insurance Contract which will pay an immediate death benefit that equals or exceeds The Total Guaranteed Funeral Price for
death from any cause, this guarantee is effective immediately; or
2. If you purchase an Insurance Contract which has a limited death benefit, this guarantee will become effective at the end of the limited death
benefit period; or
3. If you purchase an Insurance Contract through a flexible payment plan, this guarantee will be effective when the premiums paid equal or exceed
an amount equal to the Total Guaranteed Funeral Price increased by 4% annually, compounded quarterly. For example, to guarantee a $3,000
funeral price at the end of 3 years, you would have paid premiums of $3,375; $3,650 at the end of 5 years; or $3,948 at the end of 7 years. The
flexible payment plan is NOT a loan. Neither you nor your survivors are obligated to make payments under the flexible payment plan. However, if
the premiums paid are less than the amount required to obtain a guarantee your survivors must pay the Funeral Firm the difference between the
at-need retail price and the death benefit available from your total coverage.
Limitation on Price and Performance Guarantees
The Funeral Firm must be designated to receive the death benefit payable under the Insurance Contract. These guarantees will not apply if the
Insurance Contract is voided, lapsed, borrowed against, or surrendered, coverage is not purchased within 30 days, or death benefits are paid under the
suicide provision of the Insurance Contract.
Freedom of Choice Guarantee
Designating the Funeral Firm to receive the proceeds of the Insurance Contract does not restrict any right to purchase funeral merchandise or services
in the open market, with the advantages of competition, at any time before the Funeral Firm delivers the funeral.
Cancellation Guarantee
This Agreement may be cancelled at any time. Cancellation of this Agreement does not cancel your Insurance Contract, which may only be terminated
in accordance with its terms and conditions of the Insurance Contract. The owner of the Insurance Contract will receive the cash value if the Insurance
Contract is surrendered more than 30 days from issue. In the early years, the cash value may be substantially less than the premiums paid.
Disclosures
By completing this Agreement and by signing an application for the Insurance Contract, you acknowledge that: you were shown current General,
Casket and Outer Burial Container price lists prior to discussing those prices, services or merchandise; you have read, understood, and received a
copy of this Agreement; the person presenting this document is a representative of the Funeral Firm and an agent of Forethought Life Insurance
Company to whom commissions may be paid. In addition you acknowledge that to secure the Funeral Firm guarantees stated above, you direct that
proceeds are to be paid to the Funeral Firm in an amount not to exceed the retail price of the funeral provided. These directions may be changed any
time before the funeral is provided by giving written notice to Forethought Life Insurance Company.
Life Insurance/Annuity Application
Policies/Contracts Issued By:
Forethought Life Insurance Company
One Forethought Center Batesville, IN 47006-0148
FA3016-03-AZ
Page 1 of 2
Rev. 07/2019
Notice: Upon written request, Forethought will provide, within a reasonable time, reasonable factual information regarding the benefits and provisions of the contract to the contractholder. If you are
not satisfied with the annuity contract for any reason, you may return the contract within thirty days after the annuity contract is delivered and receive a refund of all premiums paid.
Section 1: Proposed Insured / Annuitant / Ownership Information
Section 1A: Proposed Insured / Annuitant
First Name
M.I.
Last Name
Social Security Number (Required)
Birthdate (mm/dd/yyyy)
Age
Gender
M F
Telephone Number
Email Address
Street Address
City
State
Zip Code
Section 1B: Certificateholder / Owner (if different from Proposed Insured / Annuitant)
First Name
M.I.
Last Name
Social Security Number/Tax Identification Number (Required)
Relationship to Proposed Insured
Telephone Number
Email Address
Street Address
City
State
Zip Code
Section 2: Health Questions
Please answer each question. All applicants must answer questions 1 and 2.
1.
Is the Proposed Insured/Annuitant currently confined to a hospital or receiving hospice care, or within the last twelve months been told by
a medical practitioner that he/she should be confined to a hospital or receive hospice care but chose to not follow that instruction?
Yes No
2.
Has the Proposed Insured/Annuitant been advised by a medical practitioner that he/she has a terminal illness or condition, or that his/her
life expectancy is twelve months or less?
Yes No
If you answered “Yes” to question 1 or 2 you will be issued the Annuity product – you do not need to complete questions 3 and 4.
3.
Is the Proposed Insured/Annuitant confined to a nursing home (including custodial care) or other such facility, or within the last twelve
months been told by a medical practitioner that he/she should be confined to such a facility but chose to not follow that instruction?
Yes No
4.
During the last five years has a medical practitioner diagnosed the Proposed Insured/Annuitant as having, or been treated for, any of the
following:
Yes No
Acquired Immune Deficiency Syndrome (AIDS)
Brain Disorder
COPD
Liver Disorder
AIDS Related Complex (ARC)
Cancer
Heart Disorder
Lung Disorder
Alzheimer’s/ Dementia
Circulatory Disorder
Insulin Dependent Diabetes
Stroke
Blood Disorder
Congestive Heart Failure
Kidney Disorder
If the Proposed Insured is seeking a Payment Plan of three (3) or more years, answers “No” to all health questions, and signs the application, full coverage will
be issued. If questions 1 and 2 are answered “No” and question 3 or 4 is answered “Yes”, or if the Proposed Insured is applying for a 1-Year Payment Plan
and answers “No” to questions 1 and 2, life insurance with limited death benefits during the first one or two years (depending on the Proposed Insured’s age
and selected payment plan) will be issued. If the Proposed Insured is applying for a Single Payment Plan and answers “No” to questions 1 and 2, life
insurance with limited death benefits during the first six months will be issued.
AUTHORIZATION: By completing the Health Questions and signing this Application, any medical doctor or facility, or other person is authorized to give
Forethought Life Insurance Company records or information regarding the Proposed Insured’s/Annuitant’s health. This authorization is limited to matters
related to the Health Questions.
Section 3: Coverage & Payment Plan
Section 3A: Life Insurance
Initial Face Amount
$
Face Amount at 6 Months (required for single premiums)
$
Payment
Plan
Single
1 Year
3 Year
5 Year
7 Year
10 Year
Other ________________
Section 3B: Annuity
Total of Planned Premium
$
Payment
Plan
Single
Section 4: Premiums (if by check, make payable to Forethought Life Insurance Company)
Single Premium
Multi-Pay Premiums
Billing Method
$
Frequency:
Initial Premium
$
Automated Payment Authorization (Section 9)
Coupon Book (monthly & quarterly multi-pay only)
Credit Card (separate payment authorization)
Monthly
Quarterly
Semiannual
Annual
+ Modal Premium
$
= Total Submitted
$
Electronic Check Disclosure: When you provide a check as the initial payment, you authorize us to either use information from your check to make a one-
time electronic fund transfer from your account or to process the payment as a check transaction. You will not receive your check back from your financial
institution.
Total premiums paid over the life of the agreement will equal the modal premiums times the number of payments, plus the initial premium. The total premiums
paid could be more than the death benefit.
Life Insurance/Annuity Application
Forethought Life Insurance Company
Page 2 of 2
Rev. 07/2019
Section 5: Replacement
Do you have any existing life insurance policies or annuity contracts?
Yes No
Is the insurance applied for intended to replace or change any existing life insurance or annuity coverage? If “Yes,” please provide name of
the insurance company(s), policy number(s), and replacement form(s) required by your state.
Yes No
Company(s): ___________________________________________________
Policy Number(s): ____________________________________
Section 6: Beneficiary
Important Information: If Section 6 is left blank, the beneficiary will be the Proposed Insured’s estate and will be paid out pursuant to the terms of the
policy/certificate including any ease of payment provisions. Please consult the policy/certificate for details upon receipt.
First Name
M.I.
Last Name
Social Security Number (Required)
Relationship to Proposed Insured
Telephone Number
Email Address
Street Address
City
State
Zip Code
Section 7: Secondary Addressee (Where to send copies of premium lapse notices – for Multi-Pay Life only)
First Name
M.I.
Last Name
Telephone Number
Street Address
City
State
Zip Code
Section 8: Agreement (Required)
The above information is true and complete to the best of my knowledge and belief. I understand that a material misrepresentation, untrue declaration, or
failure to disclose all material facts may result in loss or cancellation of coverage. I understand no coverage shall be in effect until the first premium has been
paid, a contract has been issued while the Proposed Insured/Annuitant is living, and the Proposed Insured’s/Annuitant’s insurability remains unchanged. I have
read and understand the Fraud Warnings and State Notices given to me with this application.
Signature of Proposed Insured/Annuitant (If legal representative/guardian, attach legal documentation)
X
Certificateholder/Owner Signature (if different)
X
FA3016-03-AZ
Section 9: Automated Payment Authorization
Attach voided check; Two premiums may be withdrawn the following month to keep your coverage current. To prevent this from happening you may prefer to
include an additional initial premium payment.
Name of Financial Institution
Telephone Number
Routing Number
Account Number
Checking Savings
Draw Date: Standard Date (about 30 days after issue of coverage) Custom Date ______ (Select 1-28) Deduct first payment only
I authorize Forethought Life Insurance Company to withdraw from my account the amount of premium due and request that the institution honor
such withdrawals. I agree that the Institution’s rights shall be the same as if it were a check drawn and signed by me. I further agree that if any
withdrawal fails or is disallowed neither the Institution nor Forethought Life Insurance Company shall be under any liability whatsoever. This
authorization shall continue until the Institution receives written notification from me or the contract is paid in full.
Signature of Account Holder
X
Date (mm/dd/yyyy)
Section 10: Agent’s Agreement
To the best of my knowledge, the applicant has an existing life insurance policy or annuity contract.
Yes No
Is the insurance/annuity applied for intended to replace or change any existing life insurance or annuity?
Yes No
Is the insurance/annuity being purchased with IRA or employer retirement plan (qualified plan) funds on which taxes have not been paid?
(If answer is “Yes”, a policy or annuity will not be issued.)
Yes No
Did the agent recommend that the applicant take a distribution from an IRA or employer retirement plan (qualified plan) to purchase this
insurance/annuity (whether or not taxes have been paid on the distribution)? (If answer is “Yes”, a policy or annuity will not be issued.)
Yes No
I certify that I have truly and accurately recorded herein the information supplied by the Certificateholder/Owner and Proposed Insured/Annuitant.
Product Selection: Encore/Advance Ascent EIG Other _________________________________
Printed Agent Name
Forethought Agent Number (not license number):
Agent Location
Agent Telephone Number
Agent Email Address
Street Address
City
State
Zip
Signature of Agent
X
Date (mm/dd/yyyy)
Preston Funeral Home
3800 S. Central Ave.
Phoenix
AZ
85040
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Fraud Warnings & State Notices
Forethought Life Insurance Company
A9555-02 (07-19)
Page 1 of 1
California Residents – Reg. 789.8
The sale or liquidation of any asset in order to buy insurance, either life insurance or an annuity contract, may have tax consequences. Terminating any
life insurance policy or annuity contract may have early withdrawal penalties or other costs or penalties, as well as tax consequences. You may wish to
consult independent legal or financial advice before the sale or liquidation of any asset and before the purchase of any life insurance or annuity
contract.
Colorado Residents
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or
agent of any insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Department of Regulatory Agencies.
District of Columbia Residents
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties
include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by
the applicant.
Hawaii, Kentucky and North Dakota
Any person who knowingly and with intent to injure, defraud or deceive any insurance company, submits an application for insurance containing any
materially false, incomplete, or misleading information, or conceals for the purpose of misleading, any material fact, is guilty of insurance fraud, which is
a crime and in certain states, a felony. Penalties may include imprisonment, fine, denial of benefits, or civil damages.
Kansas Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance may be guilty of insurance fraud as determined by a court of law and may be subject to fines and
confinement in prison
Maine Residents
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of def rauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Massachusetts, New Mexico and Rhode Island Residents
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Pennsylvania Residents
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
New Jersey Residents
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Virginia Residents
Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing
a false or deceptive statement may have violated the state law.
All Other States
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an
application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
Preneed New Business Options
Policies/Contracts Issued By:
Forethought Life Insurance Company
A9562-01 (06-17)
PLEASE SEE NEXT PAGE FOR INFORMATION AND INSTRUCTIONS
Page 1 of 2
Proposed Insured Name
Proposed Policy Owner/Certificate Holder (“Owner”) Name
Funeral Firm
Owner must initial all sections that apply to this sale and sign the bottom of this form.
Section 1: Direction to Pay Proceeds (Required for any sale including a Funeral Planning Agreement)
I have applied for coverage with Forethought Life Insurance Company to fund the attached Funeral
Planning Agreement with the Funeral Firm named thereon.
(Initials)
In exchange for the promises contained in the Funeral Planning Agreement, I direct the Proceeds of the
applied for coverage to be paid to the Funeral Firm in an amount not to exceed that to which the Funeral
Firm is entitled pursuant to the attached Funeral Planning Agreement. I have read and signed the
attached Funeral Planning Agreement. I have read and understand the additional terms about the
Direction to Pay Proceeds on the other side of this form.
Section 2: Change of Ownership to The Forethought Trust (Permanent and Irrevocable)
I want to make my coverage irrevocable, waiving all rights to surrender it for cash or obtain a loan.
(Except when funding an Indiana Funeral Planning Agreement, this option should only be used
when on or applying for government assistance.)
(Initials)
I hereby irrevocably assign ownership of the Forethought Life insurance policy/certificate or annuity to the
Funeral Firm identified on the attached Funeral Planning Agreement in return for the promise to deliver
funeral services and merchandise, and for the promise of the Funeral Firm to immediately transfer
ownership of the policy/certificate/annuity to the Forethought Trust on my behalf. I have read and
understand the terms under the Change of Ownership section regarding this assignment provided
on the other side of this form.
Funeral Firm’s Assignment to The Forethought Trust
On behalf of the Funeral Firm, I accept the above assignment, and hereby transfer ownership of the
policy/certificate/annuity to the Forethought Trust. I understand that any right to receive payment of the
proceeds is contingent upon delivery of the funeral services and merchandise.
Signature Required
Authorized Funeral Firm Representative Signature
Date (mm/dd/yyyy)
Section 3: Pre-planning a Funeral out of State
I am pre-planning a funeral outside of my resident state (see additional information on other
side of this form).
(Initials)
I certify that:
The information collected on the Application and Funeral Planning Agreement are true and
complete;
The proposed certificate/policy holder pre-planned a funeral with the funeral home identified in the
state identified in the application. A Funeral Planning Agreement with itemized Goods and
Services must accompany the Application or the policy will not/cannot be issued; and
The solicitation and sale of the insurance product and the signing of the application occurred
solely within the state identified on the application.
Owner is required to sign below if any section above has been completed.
Signature Required
Owner Signature
Date (mm/dd/yyyy)
Preston Funeral Home
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Preneed New Business Options
Policies/Contracts Issued By:
Forethought Life Insurance Company
A9562-01 (06-17)
Page 2 of 2
Information and Instructions
Direction to Pay Proceeds
If you completed a Funeral Planning Agreement and Goods and Services form (Guaranteed or Price Estimate Only), you
must initial Section 1 and sign where indicated.
If the Funeral Planning Agreement so provides, the amount paid to the Funeral Firm may be greater than the
retail price of the provided funeral.
These directions may be changed before the funeral is provided by giving written notice to Forethought Life Insurance
Company.
If the Funeral Firm is entitled to or claims less than the full death benefit, any remaining proceeds will be paid pursuant to
the beneficiary designation in the application, as updated by the policy owner/certificate holder by providing notice in
writing to Forethought Life Insurance Company while the insured is still living.
Change of Ownership to The Forethought Trust (Permanent and Irrevocable)
This is permanent and irrevocable, and except as stated below, eliminates the power to control the
policy/certificate/annuity.
Ownership of the policy/certificate/annuity will subsequently be transferred by the Funeral Firm to The Forethought Trust
which shall assure payment to the Funeral Firm, or any subsequently designated funeral firm, for the provision of funeral
services and merchandise.
Waiving all rights under the policy/certificate/annuity includes waiving the right to surrender it for cash and to obtain a loan
against the policy/certificate/annuity cash value. Those rights are not assigned to any other person.
The original owner must continue to pay all premiums due on the policy/certificate/annuity applied for after the
assignment.
Pursuant to the Forethought Trust, the right to change the designated funeral firm and the right to change the named
beneficiary remain with the original owner.
Alaska FPAs: The use of preneed burial contract funds is limited to burial space provisions only, as defined by Social
Security Administration.
Illinois FPAs: For certificates of insurance irrevocably assigned to a trust to fund a guaranteed-price prepaid funeral or
burial contract, upon death of any insured who was receiving government assistance, the State of Illinois will receive any
proceeds remaining payable under the certificate after payment of the designated amount for funeral goods and services
up to an amount equal to the total medical assistance paid on behalf of the insured.
Indiana FPAs: All certificates or annuities funding an Indiana Funeral Planning Agreement must be irrevocably assigned.
New Jersey FPAs: If the insured is receiving public assistance or planning to receive public assistance, any excess
proceeds not subject to the assignment to Funeral Firm, are to be paid to the State of New Jersey. This supersedes any
prior designated Beneficiary. If the insured is not receiving public assistance at the time of death, any excess proceeds
will be paid to the beneficiary designated.
Pre-planning of a Funeral out of State
Generally, insurance products should not be solicited outside the state where the owner resides. However, in some cases
it may be permissible for an owner to complete and sign an application for Forethought products in other states. Such
transactions may be proper when the owner has a significant connection to the non-resident state, such as pre-planning a
funeral, that brings the owner to the non-resident state.
Some states prohibit non-resident sales to residents of their states. From Forethought’s current interpretation of applicable
state regulations and bulletins, it appears the following states do not permit sales of insurance products to their residents
outside their state of residence, regardless of the circumstances of the case or the connection to the non-resident state:
Massachusetts, Minnesota, and Utah. If a non-resident application is submitted for a resident of one of these states, we
will decline the application.
In order for the Home Office to document the appropriateness of non-resident solicitation, completion of certification on
the front of this document is an administrative requirement whenever an owner applies for a Forethought preneed life
insurance product in a state that is not the owner’s resident state.
NOTE: this form is not an application and does not become part of the insurance contract.
Pre-Need Package Review
This form is intended to help you and your loved ones understand the services included with your Pre-Need contract
through Preston Funeral Home. Please read through this questionnaire and acknowledgment in its entirety with a
licensed agent and initial next to each (and submit with your Pre-Need contract).
INCOMPLETE FORMS MAY DELAY PROCESSING.
AGI Financial is excited you have chosen Preston Funeral Home to service your family when the unexpected occurs. You
may call Preston Funeral Home anytime with questions you may have. They are available at (602) 304-0083
Client Name: ______________________ ______________________
(Please Print) (Please Print)
__________________________________________________________________________________________________
Acknowledgements
__________ __________
(Initial) (Initial)
__________ __________
(Initial) (Initial)
__________ __________
(Initial) (Initial)
__________ __________
(Initial) (Initial)
__________ __________
(Initial) (Initial)
__________ __________
(Initial) (Initial)
_________ __________
(Initial) (Initial)
Vital Statistics
This portion is intended to assist your funeral director with the pertinent information required for filing necessary
paperwork and documents on your behalf after passing.
Maiden Name (If Applicable) ________________________________________
Father’s Name ________________________________________
Mother’s Name ________________________________________
The funeral service included in my pre need contract will be provided by the funeral home listed
on my pre need contract.
The funeral plan I purchased may include a memorial/funeral service. This will be conducted at
a location of my choosing outside of a funeral home chapel. If my loved ones choose to use a
different provider’s funeral home facility or chapel, they need to contact the funeral home listed
on my pre need contract to coordinate that service and may be subject to additional charges.
The funeral service I purchased will be honored specifically to the goods and services outlined
on my pre need contract. Changes can be made by my loved ones to the preneed contract
including additional goods and services at the time of my passing but may be subject to
additional charges.
The funeral home listed on my pre need contract will facilitate my funeral upon my passing so
long as I fulfill the contract’s applicable terms and maintain the funding.
I understand it is my responsibility to notify my loved ones that I have made this purchase.
I have received my General Price List and informational brochure for Preston Funeral Home.
I do not wish to provide my loved one’s personal contact information at this time. By doing so, I
understand my agent will be unable to discuss with them, the details of my pre-need contract
prior to my passing.
Mother’s Maiden Name ________________________________________
Veteran Yes / No
Branch of Service / NavyArmy / Air Force / Marines / Coast Guard
Current Occupation ________________________________________
Kind of Business/Industry ________________________________________
Education Level ________________________________________
Race ________________________________________
Religious Affiliation ________________________________________
Church Name ________________________________________
Cemetery ________________________________________
Location of Service ________________________________________
Informant’s Name and Phone ________________________________________ _________________________
(Who is to be contacted at the time of passing?)
________________________ _________________________
Client Signature Date Client Signature Date
_________________________
Agent Signature Date
v.4.7.1.19
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Completed 26 July 2020

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