Fillable FORM PCRA (01/2020): ALABAMA DEPARTMENT OF INSURANCE Preneed (Alabama Department of Insurance)

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FORM PCRA (01/2020): ALABAMA DEPARTMENT OF INSURANCE Preneed (Alabama Department of Insurance)

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ALABAMA DEPARTMENT OF INSURANCE
Preneed Consumer Request for Assistance
FORM PCRA (01/2020)
PLEASE TYPE OR PRINT IN BLACK INK
Before you file a request for assistance with the Department of Insurance, you should first
contact the funeral home, cemetery, or preneed sales agent in an effort to resolve the issue(s).
If you do not receive a satisfactory response, complete this form. Please mail, fax, or email it to
the address or number at the bottom of this form.
Complainant’s Name: ___________________________________________________________
Mailing Address: _______________________________________________________________
City, State, Zip Code: ____________________________________________________________
Mobile Phone: __________________________ Home Phone: __________________________
Email Address: _________________________________________________________________
Best Method of Contact: Mail Phone Email
PLEASE COMPLETE THE FOLLOWING INFORMATION TO THE BEST OF YOUR KNOWLEDGE.
1. Name of Preneed Contract Purchaser:
___________________________________________________________________________
2. Complete name of Funeral Home or Cemetery Company:
___________________________________________________________________________
3. Type of Contract (Check one): Funeral Cemetery
4. Name of Funeral Beneficiary (if different from your name):
___________________________________________________________________________
5. Contract Number(s): __________________________________________________________
(Attach copies of all contracts, front and back, if available)
Form continued on Page 2.
Alabama Department of Insurance
Examination Division – Preneed Section PCRA
Page 2 of 3
Revised 01/2020
6. Preneed Sales Agent (if applicable): __________________________________________
Telephone Number: __________________________________________
7. Have you contacted the Funeral Home or Cemetery?(Check One) YES NO
If yes, state the date(s) and person(s) contacted: __________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Attach copies of any important correspondence and/or documentation that relates to your
request for assistance. Examples: Payment receipts, cancelled checks, letters to/from the
company, notes from phone conversations, etc.
9. Have you reported this to any other agency? (Check One) YES NO
Name of Agency: __________________________________
Agency Contact: __________________________________
File Number (if known): __________________________________
10. Has anyone previously contacted the Alabama Department of Insurance about this matter?
YES NO UNSURE
(Check One)
Name on file: ____________________________________________________
Date: ______________________________
11. Have you retained an attorney? (Check one) YES NO
a. Name of the attorney/firm: _____________________________________
Firm’s Phone Number: _____________________________________
b. Is a lawsuit currently ongoing or pending? (Check One) YES NO
Form continued on Page 3.
Alabama Department of Insurance
Examination Division – Preneed Section PCRA
Page 3 of 3
Revised 01/2020
12. Briefly describe your complaint (Use additional sheets if needed):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
By signing this form, I understand that a copy of this Request for Assistance may
be provided to the Funeral Home, Cemetery, or Preneed Sales Agent.
Signature: ___________________________________________ Date: __________________
Alabama Department of Insurance
Examination Division – Preneed Section
P O Box 303351
Montgomery, AL 36130-3351
Fax: 334-206-6347
Email: Preneed@insurance.alabama.gov
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FORM PCRA (012020): ALABAMA DEPARTMENT OF INSURANCE Preneed (Alabama Department of Insurance)

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Completed 20 July 2020

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