Funeral Plan Beneficiary Form

Funeral Plan Beneficiary Form
Please complete this form to designate a beneficiary for your funeral plan. Ensure all information is accurate and up to date.
Policyholder Full Name
First NameLast Name
Policyholder Email Address
example@example.com
Policyholder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policyholder Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Beneficiary Full Name
First NameLast Name
Relationship to Policyholder
Beneficiary Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Beneficiary Email Address
example@example.com
Beneficiary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Beneficiary Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Would you like to designate an alternate beneficiary?
Alternate Beneficiary Full Name
First NameLast Name
Alternate Beneficiary Relationship
Alternate Beneficiary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allocation Percentage to Beneficiary (if more than one)
Additional Notes or Instructions
Signature
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