Name and Address Signature of Funeral Director Funeral Director License No. Tax I. D. Number Form 47 PA Rev. 6/2006 Email Address Date. INVESTORS HERITAGE Life Insurance Company 200 Capital Avenue P O Box 717 Frankfort Kentucky 40602-0717 Toll Free 800 422-2011 Fax 502 223-6575 PENNSYLVANIA Click here to reset form FUNERAL DIRECTOR S STATEMENT Use ONLY for Non-Contestable Preneed Claims INSTRUCTIONS Mail completed form with the Policy and Obituary Newpaper Clipping. Name of Deceased Social Security Number Address P. O. Box - No* - Street City Male Female State Issue Date of Policy ies Policy Number s Deceased was Zip Code Type of Policy ies Life Insurance Date of Birth // Place of Birth City and State Annuity Place of Death Date of Death Month / Day / Year PRIMARY CAUSE OF DEATH as listed on the death certificate filed with the Bureau of Vital Statistics Where did death occur Please check one Hospital Nursing Home Residence Other Name of Person Arranging Funeral Relationship to Dece....
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How to fill out the PA Form 47 PA online
This guide provides a clear and detailed approach to completing the PA Form 47 PA for funeral director's statements. Whether you are a seasoned professional or new to the process, these instructions will help ensure that all necessary information is collected accurately.
Follow the steps to fill out the PA Form 47 PA online
- Click ‘Get Form’ button to access the form and open it in your preferred editing software.
- Begin by entering the name of the deceased in the designated field. Make sure to check the spelling for accuracy.
- Provide the Social Security number of the deceased. This information is crucial for identification purposes.
- Fill out the address of the deceased, including the P.O. Box, street number, and street name. Ensure that the city, state, and zip code are correctly entered.
- Indicate the issue date of the policy or policies related to the deceased.
- List all relevant policy numbers associated with the deceased. Ensure each number is placed in its own designated field.
- Select the type of policy for each insurance policy listed. This could include options such as life insurance or annuity.
- Enter the date of birth of the deceased in the specified format (MM/DD/YYYY) and their place of birth, including city and state.
- Record the place and date of death similarly to the date of birth, making sure the details match official records.
- Fill in the primary cause of death as noted on the death certificate and choose the location where the death occurred.
- Provide the name and relation of the person arranging the funeral, along with their Social Security number and address.
- Include the contact telephone number of the arranging person.
- Indicate whether the policy proceeds have been assigned by selecting 'Yes' or 'No'.
- Confirm if the newspaper obituary is attached by selecting 'Yes' or 'No'.
- The licensed funeral director must then certify their authority by signing and entering their name, licensing number, telephone number, and tax identification number.
- Finally, save the completed form, ensuring that all information is accurate before printing, sharing, or downloading the document.
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