Get PA Form 47 PA 2006-2024

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 Deceased Telephone Number Were the Policy Proceeds Assigned Yes No Is the Newspaper Obituary Attached I hereby certify that I am an authorized licensed Funeral Director that the above named Insured is deceased as set forth above that I will/have prepare d for final disposition the body of the above named person and that I will/have fully perform ed the funeral services for the above named person* I hereby certify that all information above is true and correct to the best of my knowledge and belief* I understand that the life insurance policy is not contestable because it was guaranteed issue or because it has been in effect for two 2 years from the date of issue. The Obituary newspaper clipping the Certificate of Performance if required by state law and the policy should accompany this form* Investors Heritage reserves the right to request additional information which it in its sole discretion deems necessary to adjudicate a claim* Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or settlement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent act which is a crime and subjects such person to criminal and civil penalties. 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 Deceased Telephone Number Were the Policy Proceeds Assigned Yes No Is the Newspaper Obituary Attached I hereby certify that I am an authorized licensed Funeral Director that the above named Insured is deceased as set forth above that I will/have prepare d for final disposition the body of the above named person and that I will/have fully perform ed the funeral services for the above named person* I hereby certify that all information above is true and correct to the best of my knowledge and belief* I understand that the life insurance policy is not contestable because it was guaranteed issue or because it has been in effect for two 2 years from the date of issue. .