Insurance Cremation Contract

INSURANCE CREMATION CONTRACT

Provider and Contract Identification

Provider Name:

Provider License/ID:     Phone:

Applicant / Insured Information

Relationship to Decedent:     Phone:

Date of Birth:     Date of Death (if known):

Policy and Contract Coverage

Policy Number:     Policy Type:

Coverage Amount:     Deductible:     Premium / Fee:

Policy Period Start:     Policy Period End:     Payment Frequency:

Covered Services and Optional Items

Select services provided under this contract (check all that apply):

Basic Cremation (professional services, facility, cremation processing)

Witnessed Cremation (family may witness cremation)

Viewing/Transfer and Care Prior to Cremation

Memorial Service / Facility Use

Transportation of Decedent (to facility)

Standard Urn (describe below)

Urn / Container Selection and Disposition

Urn Type/Description:

Beneficiary Designation

Beneficiary Name:     Relationship:

Percentage of Proceeds / Responsibility:

Authorizations, Warranties and Certifications

I hereby certify and warrant that I am the lawful authorized agent to contract for the cremation, disposition, and related services described in this contract. I authorize the Provider to perform cremation services for the decedent named herein and to take all actions necessary to effect the services selected. I certify that the information provided in this contract is true and correct to the best of my knowledge.

I acknowledge and understand that cremation is an irreversible process and that the Provider will rely upon the identification and authorization provided by me. I release, indemnify, and hold harmless the Provider and its agents from liability for carrying out the services in accordance with this contract, except for gross negligence or willful misconduct.

Exclusions, Limitations and Permits

The Provider shall not be responsible for items of property retained with the decedent without written authorization. This contract does not include cemetery interment fees, governmental permits, death certificates, or additional transportation charges unless expressly stated. Provider will not cremate pacemakers or other hazardous devices unless removed prior to cremation. All services are subject to applicable law, regulations, and licensing requirements.

Cancellation, Refunds and Unclaimed Remains

Applicant may cancel this contract within the period allowed by law. If services have not been rendered and cancellation is timely, a refund will be made in accordance with Provider refund policy less any reasonable administrative charges disclosed in itemized costs. If the cremated remains are not claimed within the period required by law or by Provider policy, Provider may take lawful steps for final disposition; Provider may recover storage and disposition costs from any funds or from the estate.

Claims, Notices and Records

All claims for breach, error, or omission related to the services provided under this contract must be submitted in writing to the Provider within the time specified by applicable law. Provider will retain records of cremation and disposition in compliance with licensing requirements and will provide certified copies upon lawful request.

Acknowledgement and Certification

By signing below I certify under penalty of perjury that I am authorized to contract for the cremation and disposition of the decedent identified in this contract. I acknowledge receipt of an itemized statement of services, costs, and the Provider's cremation procedures. I understand and accept the limitations, exclusions, and indemnities contained herein.

Applicant represents and warrants that all persons with superior legal rights to control final disposition have been notified or that applicant has sole authority. Applicant agrees to indemnify Provider for any claims arising from misrepresentation of authority.

Initial that you have read and accept the major provisions:     Cremation Authorization:     Exclusions & Liability:     Disposition Instructions:

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