Get Information Form Pre Need

Mausoleum 2. Grave Site 3. Vault 4. Crypt 5. Casket 6. Urn 7. Headstone 8. Open/Close 9. Other Signature Funeral Home or Insurance Company Representative Form H1238-A/12-2009 Verification of Pre-Need Information. Date/Fecha Caseworker/Trabajador Funeral Home or Insurance Company Name and Address Office Address Area Code and Telephone No* Oficina Clave del rea y Tel fono This person is being considered for assistance. The requested information as well as information about any additional contracts or policies will assist me in arriving at a determination* A signed authorization to release information is enclosed* Name of Applicant/Recipient Contract or Policy No* Comments Area Code and Telephone No* Signature Eligibility Specialist Contract No* 1 Date 2. Owner 3. Insured If Other than Owner Yes 6. Cancellation Penalty If Yes list percentage or amount of penalty Penalty 4. Paid in Full 5. Burial Space Items Paid First No Penalty 7. Face Value 8. Cash Value 9. Balance Due 10. Funded by Annuity or Trust 11. Funded by Insurance Policy If funded by insurance please provide insurance company name address and telephone number so we can contact the insurer. 12. Is Assignment Revocable or Irrevocable Please check the appropriate box. Revocable Irrevocable 13. If changed from revocable to irrevocable the effective date of the change Please List Value for Each Item 1. Date/Fecha Caseworker/Trabajador Funeral Home or Insurance Company Name and Address Office Address Area Code and Telephone No* Oficina Clave del rea y Tel fono This person is being considered for assistance. The requested information as well as information about any additional contracts or policies will assist me in arriving at a determination* A signed authorization to release information is enclosed* Name of Applicant/Recipient Contract or Policy No* Comments Area Code and Telephone No* Signature Eligibility Specialist Contract No* 1 Date 2. The requested information as well as information about any additional contracts or policies will assist me in arriving at a determination* A signed authorization to release information is enclosed* Name of Applicant/Recipient Contract or Policy No* Comments Area Code and Telephone No* Signature Eligibility Specialist Contract No* 1 Date 2. Owner 3. Insured If Other than Owner Yes 6. Cancellation Penalty If Yes list percentage or amount of penalty Penalty 4. Owner 3. Insured If Other than Owner Yes 6. Cancellation Penalty If Yes list percentage or amount of penalty Penalty 4. Paid in Full 5. Burial Space Items Paid First No Penalty 7. Face Value 8. Cash Value 9. Balance Due 10. Paid in Full 5. Burial Space Items Paid First No Penalty 7. Face Value 8. Cash Value 9. Balance Due 10. Funded by Annuity or Trust 11. Funded by Insurance Policy If funded by insurance please provide insurance company name address and telephone number so we can contact the insurer. Funded by Annuity or Trust 11. Funded by Insurance Policy If funded by insurance please provide insurance company name address and telephone number so we can contact the insurer. 12. Is Assignment Revocable or Irrevocable Please check the appropriate box. Revocable Irrevocable 13.