Serenity Assurance
Final Expense Burial Information Form
Burial & Final Expense Savings for Seniors
Securely enter the information below and we look forward to getting you and your loved ones the information on saving thousands on burial, cremation and final expenses. Haven’t you waited long enough to get the peace of mind and dignity you deserve in getting affordable and comfortable coverage for Final Expense/Burial? Get qualified TODAY in just a couple minutes for your own custom plan for: Immediate Benefit Plans, Guaranteed Issue Plans, 24-48 Hour payout, $1000-$30,000, Cost never changes, Whole Life Plan Inflation Buster! Locked In wholesale savings on casket, vault, headstone, urns, and funeral home costs at today’s prices.
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My information will kept private and confidential, and never be sold or provided to 3rd parties without my consent. The information to follow is very important to best help you and takes most clients 2-3 minutes to complete. (For Quicker Entry You May Choose to Scroll to Submit)
For Quicker Entry You May Choose to Scroll to Submit. Red asterisks are required entries.
Name
*
First
Last
Age
Final for talk
Date of Birth (MM/DD/YYYY)
Consent
*
I consent to be contacted with the information I am requesting
Basic Info
Email
*
Address
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
City (If not entering full address)
State (If not entering full address) (copy)
Phone
*
*
This phone receives text messages
Next
Information to Confirm Your Identity For Follow Up
Favorite Color
*
Favorite Past Time/Hobby
*
The Information Below Is Very Important to Be Able to Best Serve You
Enter what you feel comfortable with. It is the information that we need to best serve you, and work together for your perfect plan! (For Quicker Entry You May Choose to Scroll to Submit)
Beneficiary (Person Responsible to Pay Final Expenses and Receive Additional Funds)
If God forbid you were to pass away tonight, who would have to take responsible for your final expenses and arrangements.
Looking for yourself or a loved one?
Myself
A Loved One
Both of Us
How long have you been looking into final expense burial plans?
Just started
A couple of weeks
More than a month
Tell us about what prompted and motivated you to respond today for more information.
Have you ever had to plan or pay for a loved ones funeral?
No, I have never had to.
Yes, I have and had to pay out of pocket
Yes, I have and there was life insurance
Tell us about your experience with having to plan or pay for a loved one's funeral and final expenses.
Have you decided on traditional burial or cremation?
Traditional Burial
Cremation
Not sure yet
Do you have Life Insurance
No
Term Insurance
Whole Life Insurance
Not sure what kind I have, something
Purpose of Coverage
Cover All Final Expenses
Cover All Final Expenses & Leave a Legacy Gift of Love
What is most important to you? (Select all that apply)
Save thousands on my final expenses
Affordable and comfortable payment
Having adequate coverage amount
Coverage Amount You Desire
$1,000-$4,999
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000 or more
Affordable and Comfortable Payments
$49 and under
$50-$74
$75-$99
$100-$149
$150-$174
$175-$199
$200 or more
This is State Regulated Coverage by a Stated Authorized Insurance Company
Yes, I understand and that is what I am looking for
Final Expense Burial Insurance is commonly sold over the phone by State Regulated and Licensed Professionals. I understand that when I am ready and comfortable, the following information is needed to provide the best coverage for the most affordable rates.
I understand that
At least the last 4 digits of SSN will be needed
I understand that
Only medical questions are needed, NO doctor appt, blood or urine tests.
I understand that
Most insurance companies offer discounts for automatic withdrawals from checking accounts
I understand that
When I am comfortable and ready, I will need to provide method of payment to secure coverage.
I understand that
The Licensed Agent helping me is required to provide their licensing credentials
Death, Dying and Final Arrangements are never easy topics to discuss, and frequently our family is just as reluctant to talk about, so getting coverage and protection continues to be procrastinated about. Give the gift of peace of mind and dignity to yourself and loved ones, and let us help take care of that for you. It is our Mission!
Comments or Questions
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