goinghomecremations

    INSURANCE ASSIGNMENT AUTHORIZATION

    Deceased Name:   Date of Death:

    Insurance Company:

    Policy Number:   Claim Number:

    Insurance Company:

    Beneficiary Name(s):

    ASSIGNMENT OF INSURANCE PROCEEDS

    I/We, the undersigned beneficiary(ies) of the above-referenced insurance policy, hereby authorize and direct the insurance company to pay directly to Going Home Cremations the sum of:

    Amount Assigned: $   Written Amount

    for cremation services, transportation, permits, death certificates, merchandise, and any other funeral or cremation-related charges provided by Going Home Cremations.

    I/We understand that this assignment is limited to the amount stated above and that any remaining insurance proceeds are payable to the designated beneficiary(ies) according to the terms of the policy.

    I/We certify that I/we have the authority to make this assignment and agree to cooperate with any documentation reasonably required by the insurance company to process this payment.

    PAYMENT INSTRUCTIONS

    Please make check payable to and mail insurance proceeds to:

    Going Home Cremation – Executive Offices
    101 Old Eastlake Rd.
    Tarpon Springs, FL 34688

    Any balance remaining after payment of funeral expenses shall be paid to the named beneficiary by the insurance company.

    BENEFICIARY SIGNATURE

    Printed Name:

    Signature:

    Date:

    Phone:

    CO-BENEFICIARY SIGNATURE (IF APPLICABLE)

    Printed Name:

    Signature:

    Date:

    Phone:

    WITNESS SIGNATURE

    Printed Name:

    Signature:

    Date:

    Phone:

    GOING HOME CREMATIONS REPRESENTATIVE

    Printed Name:

    Signature:

    Date:

    Phone:

    PHONE:

    941-320-1179
    727-249-4949

    SERVING FAMILIES THROUGHOUT:

    Pinellas County • Pasco County • Hillsborough County
    Sarasota County • Charlotte County • Lee County

    Because dignity should never be discounted.