Fillable AZ NGL Pre Filled Application Example 2

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AZ NGL Pre Filled Application Example 2

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  • 40 check-boxes
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EXHIBIT A AGREEMENT NUMBER ______________
NON-GUARANTEED CASH ADVANCE ITEMS
FUNERAL HOME SERVICES:
Basic Services of Funeral Director and Staff ........ $ ____________
Embalming ............................................................ $ ____________
Use of facilities/staff/equipment for:
Visitation _____ days @ $ _______ per day . $ ____________
Funeral/Memorial Service..................................... $ ____________
Graveside Service ................................................. $ ____________
Transfer of deceased to Funeral Home
( __________ Miles) ...................................... $ ____________
Family car(s) Number ____ @ $ _____ each .. $ ____________
Hearse ................................................................... $ ____________
Service Vehicle ..................................................... $ ____________
Forwarding/Receiving remains.............................. $ ____________
Other Services/Facilities/Equipment:
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
TOTAL FUNERAL HOME SERVICES ........................... $
GUARANTEED FUNERAL GOODS AND SERVICES
Acknowledgement Cards....................................... $ ____________
Obituary Notices.................................................... $ ____________
Death Certificate(s) ( # ______________ ) ..... $ ____________
Flowers.................................................................. $ ____________
Clergy Honorarium ................................................ $ ____________
Music .................................................................... $ ____________
Vault Installation ................................................... $ ____________
Grave Opening and Closing .................................. $ ____________
Hairdresser ............................................................ $ ____________
Other (Specify)
___________________________________ $ ____________
___________________________________ $ ____________
Funeral Home Name
Address
Signature of Authorized Funeral Home Representative Date
Purchaser
Address
Signature of Purchaser Date
FUNERAL MERCHANDISE:
Casket.................................................................... $ ____________
Construction & Type _____________________
Fabric _______________________________
Special Features _______________________
Manu./Model or Name ___________________
Cremation Container ............................................. $ ____________
Manufacturer __________________________
Model Name/Number ____________________
Outer Burial Container........................................... $ ____________
Manufacturer __________________________
Model Name/Number ____________________
Material ______________________________
Other Guaranteed Merchandise (Specify)
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
___________________________________ $ ____________
TOTAL FUNERAL MERCHANDISE .............................. $
TOTAL FUNERAL HOME SERVICES ........................... $ +
TOTAL GUARANTEED FUNERAL PRICE ...................... $
We charge you for our services in obtaining the
following cash advance items:
___________________________________ $ ____________
___________________________________ $ ____________
Sales Tax _____________________________ $ ____________
TOTAL NON-GUARANTEED CASH ADVANCE ITEMS ... $
TOTAL GUARANTEED FUNERAL PRICE ...................... $ +
TOTAL GUARANTEED AND NON-GUARANTEED
FUNERAL PRICE ............................................... $
THIS FUNERAL CONTRACT IS FUNDED BY LIFE INSURANCE
PN-REI-SGS-AZ 07/02PN-REI-SGS-AZ 07/02
PN-REI-SGS-AZ 07/02PN-REI-SGS-AZ 07/02
PN-REI-SGS-AZ 07/02
1st Copy – Company 2nd Copy – Agent 3r1st Copy – Company 2nd Copy – Agent 3r
1st Copy – Company 2nd Copy – Agent 3r1st Copy – Company 2nd Copy – Agent 3r
1st Copy – Company 2nd Copy – Agent 3r
d Copy – Pd Copy – P
d Copy – Pd Copy – P
d Copy – P
urur
urur
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chaserchaser
chaserchaser
chaser
STATEMENT OF GOODS AND SERVICES
Charges are only for 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. If you select 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 direct cremation or immediate burial. If
we charge for embalming, we will explain why below. ______________________________________________________________________
______________________________________________________________________________________________________________
Acknowledgement: By completing and signing this form, you acknowledge that you were given a copy of this agreement, that you were shown general price
lists prior to discussing prices of funeral services or merchandise and that you have read and understand this agreement.
(NAME) JOHN DOE
(SS#)123456789
1595.00
395.00
225.00
2215.00
200.00
SHEET METAL URN
225.00
225.00
650.00
2215.00
2865.00
Discount
-400.00
57.30
57.30
2465.00
2522.30
Preston Funeral Home
3800 S. Central Ave. Phoenix, AZ 85040
JOHN DOE
123 MAIN ST, ANY CITY, AZ 12345
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signature
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PREFUNDED FUNERAL AGREEMENT
Performance Agreement
The Provider agrees to provide the funeral services as specified by the Purchaser on Exhibit A unless those services cannot be performed due
to circumstances beyond the Provider’s control. This Agreement supercedes any and all other written agreements and negotiations between
the parties. This agreement cannot be changed except by a later written agreement signed by Purchaser and Provider.
Funding
Purchaser agrees to fund this Agreement with a life insurance policy issued by National Guardian Life Insurance Company (“Insurer”) on the
life of the Recipient with an ultimate face amount at least equal to the Total Guaranteed and Non-Guaranteed Funeral Price and to assign the
policy proceeds to the Provider. The policy shall be purchased within 30 days from the date of this agreement.
The Insurer is not a party to this Agreement and is not responsible for fulfillment of its terms. The responsibilities of the Insurer are solely as
stated in the insurance policy.
Price Guarantee
The prices shown in the Statement of Goods and Services are the current retail prices. They are used to establish the amount of insurance
required to fund this Agreement. When the Funeral Services are provided, the current retail prices at that time will be charged. The provider
will accept the policy death benefit as full payment for the Guaranteed Funeral Goods and Services, even if the then retail price is greater than
the policy death benefit. Prices for Cash Advance items are incidental and not guaranteed.
If the total policy death benefit is not sufficient to provide payment in full, the difference between the policy death benefit and total price of the
Funeral Services will be due and payable by the recipient’s family or authorized representative. If the actual death benefits exceed the then-
current retail prices, the Provider may retain the excess.
Limitation on Price Guarantee
These price guarantees will not apply unless the policy death benefit paid is an amount at least equal to the ultimate face amount.
Substitution of Funeral Services
The Provider will furnish the items as described, but, if unavailable, reserves the right to substitute items of equal or better quality.
Freedom of Choice
At any time, Purchaser, family or authorized representative may request that a new funeral home be appointed to provide the Funeral Services.
This request must be in writing. Upon acceptance by the new funeral home, Provider agrees to assign its rights and obligations in this
Agreement.
Insurance Policy Termination
If the insurance policy is terminated for any reason, this Agreement automatically ends and the Provider is relieved of all responsibility under
the Agreement. This Agreement automatically ends if the insurance policy is cancelled, allowed to lapse, borrowed against, surrendered for
cash, or if annuity payments are paid out before death.
Cancellation
This Agreement may be cancelled at any time before the Provider provides the Funeral Services. Cancellation of this Agreement
will not cancel the insurance policy, which must be cancelled according to the specific terms of the insurance policy. If the insurance policy
is cancelled or surrendered more than 30 days from issue, the cash value, if any, will be refunded. In the early years, the cash value may be
substantially less than the premiums paid.
PROPOSED INSURED/ANNUITANT Male Female
_________________________ _____ _______________________ _______________________ ______________________ _____ ________________
First Name MI Last Name Phone Number Social Security Number Age Date of Birth
OWNER - Complete only if other than Insured/Annuitant
__________________________________ _____ _________________________________ _____________________________ ____________________
First Name MI Last Name Social Security Number Relationship to Insured
OWNER MAILING ADDRESS
_____________________________________________ ___________________________ _______ ____________ ______________________________
Street Address City State Zip Email Address
Funeral Price $__________ Face Amount $__________ PLAN A B C
PAYMENT PLAN Single Pay Life Flexible Annuity $________ Multi Pay Life: 3 Year 5 Year 10 Year
Initial Premium + Multi Pay Premium = Total Premium Amount (with app)
$__________ $____________ $__________
PAYMENT MODE
Annual Semi-Annual Quarterly Monthly Direct EFT* MC/VISA*
*Complete the premium withdrawal authorization
This Policy will fund a: Burial Cremation Other
STATEMENT OF HEALTH (To be completed by Proposed Insured - Do not complete for Annuity): Are you currently on oxygen,
hospitalized, receiving hospice care, or conned to a nursing home or long term care facility; or during the past two years have you
been advised by a medical professional to have any surgical procedure that has not been performed; or have you been treated or are
you being treated (including medication) by a medical professional for any of the following diseases or disorders:
YES
NO
Congestive Heart Failure
Heart Disease
Stroke
Cancer (other than skin)
Immune System Disorder
Cirrhosis of the Liver
Drug or Alcohol Dependency
Kidney failure (including dialysis)
Chronic Obstructive Pulmonary (lung) Disease
Emphysema
Amyotrophic Lateral Sclerosis (Lou Gehrig’s
Disease)
Diabetic Coma/Insulin Shock
Amputation (caused by disease)
Alzheimer’s/Dementia
If the health question is not answered or answered “Yes” and you are applying for a Multi Pay Plan, a Policy with limited
death benets during the early years will be issued. The full death benet is paid for accidental death.
DIRECTION FOR PAYMENT OF PROCEEDS (DO NOT COMPLETE UNTIL YOU HAVE READ THE LAST PAGE OF THIS FORM
FOR IMPORTANT INFORMATION)
______________________________________________ ____________________________________ ___________________ ______ ______________
Name of Funeral Provider Street Address City State Zip
__________________________________ ___________________________ __________________ ______ ______________ _____________________
Name of Primary Beneciary Street Address City State Zip Relationship to Insured
APPLICANT SIGNATURES
To the best of my knowledge and belief, the above information is true and complete. I understand that no insurance will be
effective until this form is approved and the Policy is issued while the Insured is living. I authorize NGL to share my nonpublic
personal information with any Funeral Provider with whom I have a Prefunded Funeral Agreement. If I am the Owner for
insurance on the life of the Proposed Insured, I certify that I have an insurable interest in his or her life. I acknowledge that I
have read the fraud warning statement on the last page of this form.
IRREVOCABLE ASSIGNMENT: I elect to assign this Policy subject to the terms of the Irrevocable Assignment of Policy on
the last page of this form. Owner Initials
__________
(Initial only if the Policy should be irrevocably assigned.)
________________________________________________________________________________________ ___________________________________
Signed At State
___________________________________________ __________________ __________________________________________ __________________
Signature of Proposed Insured/Annuitant Date Signature of Owner (Required if other than Insured) Date
AGENT’S STATEMENT I certify that any information recorded by me on this form is true and accurate to the best of my knowledge.
___________________________________ _______________________________________ ______________________
Check here for Agent Split
Agent Signature Agent Name Printed NGL Agent #
and see last page
3315PN 07/12 1st Copy - Company 2nd Copy - Agent 3rd Copy - Purchaser
ENROLLMENT FORM FOR GROUP INSURANCE/ANNUITY
National Guardian Life Insurance Company (NGL) - Phone 800.988.0826 - Fax 866.228.9927
Two East Gilman Street - PO Box 1191 - Madison WI 53701-1191
Mail Policy To: Agent
Funeral Home
Owner (Default)
3315PN(v4) 07/12 Series 64
(
Single and Annual payments only)
✔
✔
JOHN
DOE
1234567890
123456789
45
1-1-74
2522.30
2589.67
✔
✔
40.00
✔
✔
✔
Preston Funeral Home
3800 S. Central Ave.
Phoenix
AZ
85040
JANE DOE
SPOUSE
ANY CITY
AZ
10.1.19
JIM AGENT
123456
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signature
click to edit
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signature
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signature
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DIRECTION FOR PAYMENT OF PROCEEDS: By naming a Funeral Provider under the DIRECTION FOR PAYMENT OF
PROCEEDS, you agree to the following: NGL is directed to pay an amount not to exceed the death benet of the Policy to the
Funeral Provider named, if any, on the front of this form. NGL will only pay the Funeral Provider upon receipt of proof that funeral
merchandise and services have been provided. You may change these directions at any time before the funeral is provided by
giving written notice to NGL. In the event that NGL rescinds or declines to issue the Policy, you also assign the following to the
Funeral Provider: (1) The right to receive the premium paid upon receipt of proof that funeral merchandise and services have been
provided; (2) The right to compromise claims; and (3) The right to agree to rescission.
IRREVOCABLE ASSIGNMENT OF POLICY: If initialed, you agree to the following: Assignment of Ownership, Death Benet
and Rescission Rights: The Owner hereby irrevocably assigns to the Funeral Provider named in the Direction for Payment of
Proceeds all incidents of ownership of the Policy, the right to receive all or part of the death benet payable under the Policy upon
receipt of proof that the funeral merchandise and services have been provided, and, if the Insurer, for any reason either rescinds or
declines to issue a Policy, all rights, including the following: (1) the right to receive the premium paid (upon receipt of proof that the
funeral merchandise and services have been provided), (2) the right to compromise claims and (3) the right to agree to rescission.
The Owner acknowledges that by making the assignment irrevocable it cannot be canceled. This assignment does not affect the
right of the Owner to cancel the Policy under the Right to Cancel provision. By making this assignment irrevocable, the Owner also
acknowledges the following: (1) The assignment of death benet proceeds is permanent and cannot be changed by the Owner; (2)
The Owner has waived all rights under the Policy to surrender for cash, to obtain a loan, to change the Owner or beneciary, or to
receive a refund for any premium paid; and (3) The Owner remains responsible for the payment of all insurance premiums when
due.
It is understood and agreed that this irrevocable assignment in no way inhibits the Owner or the next of kin of the Insured from
hereafter selecting another Funeral Provider to perform funeral services and provide funeral merchandise in connection with the
funeral of the Insured. The Insurer is not a party to this assignment and the sole responsibility of the Insurer is to pay the death
benet proceeds pursuant to the terms of the Policy as amended by this assignment.
AGENT SPLIT DESIGNATION: Please list any agents not included in the AGENT’S STATEMENT section.
Agent listed in AGENT’S STATEMENT % _________________________________
_______________________________________ ___________________________________________ ____________________________ _____________
Additional Agent Signature Additional Agent Name Printed Additional NGL Agent # %
ACKNOWLEDGMENT OF PAYMENT: This acknowledges payment from ____________________________________ in the amount of
$______________________in connection with the Policy applied for from NGL. If all of the conditions of the application are met and the
application is accepted, a Policy will be issued. If the application is not accepted, the Insurer’s only responsibility will be to refund the
amount for which this Acknowledgment of Payment was given.
ELECTRONIC CHECK DISCLOSURE: When you provide a check as 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.
When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as
soon as the same day you make your payment, and you will not receive your check back from your nancial institution. In the
event that the payment is not honored, NGL has the right to re-present the transaction. For inquiries please call 1.800.988.0826.
FRAUD WARNING STATEMENTS
For Residents of DE, HI, ID, MO, MS, NV, SC, WV and WY: Any person who knowingly and with intent to defraud an insurer
submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.
For Residents of AL, DC, LA and RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benet or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
For Residents of KS and NE: Any person who knowingly and with intent to defraud an insurer submits a written application or
claim containing any materially false or misleading information may be guilty of insurance fraud.
For Residents of Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person
who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
For Residents of New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil nes and criminal
penalties.
3315PN 07/12 “Policy” is dened as the insurance policy, certicate or annuity contract for which I am applying.
JOHN DOE
40.00
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signature
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or
Bank Account Information:
Financial Institution (Bank Name): ___________________________________________________
Routing # (lower left corner of check): Bank Account # (lower middle of check):
Authorization: I authorize National Guardian Life Insurance Company (NGL) to make:
q A one-time initial (will be drawn immediately)
q A one-time initial and ongoing (initial will be drawn immediately)
q Ongoing only
withdrawal(s) from my bank account/credit card specied above. By signing below, I certify that I have
read the withdrawal authorization disclosures on the reverse side of this form.
q Checking q Savings* q Credit Card Draft Date for Ongoing Withdrawal Only (1st-28th):_____
Amount of Initial Premium Withdrawal:___________Amount of Ongoing Withdrawal:_____________
Insured’s Full Name (Please Print):_____________________ _______ ______________________
Accountholder/Cardholder’s Name:____________________ _______________________________
Accountholder/Cardholder’s Signature: ______________________________Date:_______________
*FOR SAVINGS ACCOUNTS, PLEASE CONTACT YOUR BANK TO VERIFY EFT IS ALLOWED
AND TO VERIFY ROUTING AND ACCOUNT NUMBERS
2802 p2 01/19
Premium Withdrawal Authorization
Complete One Premium Withdrawal Authorization for Each Insured
National Guardian Life Insurance Company (NGL) • PO Box 1191 • Madison, WI 53701-1191
First
Last
Middle Initial
Credit Card:
q VISA
q MASTERCARD
EXP.
DATE
M M Y Y
First
Last
FOR INITIAL AND ONGOING
WITHDRAWALS FROM A BANK ACCOUNT,
PLEASE TAPE A VOIDED CHECK HERE
AND COMPLETE
THE FINANCIAL INSTITUTION,
ROUTING NUMBER AND BANK
ACCOUNT NUMBER.
(For Single and Annual Payments Only)
ABC BANK
8 7 6 5 6 5 4 8 9
1 2 3 4 5
40.00
40.00
JOHN
DOE
JOHN
DOE
10.1.19
✔
✔
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signature
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Withdrawal Authorization Disclosures:
Initial Premium Withdrawal: I authorize National Guardian Life Insurance Company (NGL) to make a one
time withdrawal from my bank account/credit card for the amount provided on this form, not to exceed the amount
indicated in my policy contract and/or policy endorsement. The draw will be started on the date the application is
approved, but the actual date of withdrawal can vary due to holidays/weekends and is dependent on my Financial
Institution. This withdrawal is for the purpose of collecting the initial premium for my policy. I authorize the nancial
institution to process the withdrawal as if I had signed it. In the event that the payment is not honored, NGL has
the right to re-present the transaction. NGL also has the right to revoke this method of payment at any time.
Ongoing Monthly Credit Card Withdrawal: I authorize National Guardian Life Insurance Company (NGL)
to remit the premiums due through my credit card indicated for the amount and date provided on this form or as
stated in the policy contract and/or policy endorsement I will receive. Unless indicated the draw will occur monthly.
This authority will remain in full force and effect until the stated expiration date of the card or until I revoke this
authorization with ve day advance written notice. NGL has the right to revoke this method of payment at any
time. This withdrawal is authorized only if I have selected ongoing withdrawals on the reverse side of this form.
Ongoing Monthly Electronic Funds Transfer (EFT): I authorize National Guardian Life Insurance
Company (NGL) to electronically debit my bank account for the amount and date provided on this form or as
stated in the policy contract and/or policy endorsement I will receive. The actual date of deduction can vary due
to holidays/weekends and is dependent on my Financial Institution. This authorization is to remain in effect until
canceled. This method of payment can be canceled with ve day advance written notice. In the event that the
payment is not honored, NGL has the right to re-present the transaction. This method of payment will not change
any of the provisions of my policy and unless indicated the draw will occur monthly. NGL has the right to revoke
this method of payment at any time. This withdrawal is authorized only if I have selected ongoing withdrawals on
the reverse side of this form.
Electronic Check Disclosure: When you provide a check as payment, you authorize us either to 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. When we use information from your check to make an electronic fund transfer,
funds may be withdrawn from your account as soon as the same day you make your payment, and you will not
receive your check back from your nancial institution. For inquiries please call 1-800-988-0826.
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.
JOHN DOE
JD
JD
JD
JD
JD
JD
JD
NA
JIM DOE
JANE DOE
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
✔
✔
123-456-7890
JOHN DOE
JIM DOE
10.1.19
10.1.19
NA
HOME
SAM DOE (SON)
JANE SMITH
RETIRED
PREVIOUS - SALES
COLLEGE
WHITE
CHRISTIAN
ALL FAITH
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AZ NGL Pre Filled Application Example 2

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Completed 26 July 2020

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