Fill and Sign the Life Insurance Disclosure Model Regulation 580 Naic Form

Prearranged Funeral Contract with Statutory Disclosures This Agreement is made _______________ (date), between ________________________ (Name of Funeral Provider), a corporation organized under the laws of ______________ (name of state), having its principal office at __________________________________________________________ ____________________ (address of funeral provider) (the Funeral Provider), and ______________________ (Name of Purchaser), of _____________________________________ _____________________________________________ (address of Purchaser) (the Purchaser).1. The Purchaser agrees to purchase, at the prices indicated, services and merchandise which conform to the description listed below, and there shall be furnished such services and merchandise upon payment by the Purchaser of the price set forth in this Agreement. The parties acknowledge that should the merchandise listed below not be available at the time of need, then merchandise of equal or greater quality shall be substituted.2. _______________ (I was/We were) given a General Price List and chose:Funeral Services: (description of funeral services) ______________________________________ ________________________________________________________________________________ ________________________________________________________________________________[ ] Burial[ ]Entombment[ ] Cremation[ ] TransferProfessional Services $________ (dollar amount of professional services fee)Care of Remains $________ (dollar amount of fee for care of remains)Use of Facilities and Equipment $________ (dollar amount of fee for use of facilities and equipment)Automotive Equipment $________ (dollar amount of fee for automotive equipment)Total Funeral Services Selected $_______ (dollar amount of fee for total funeral services)Merchandise: $________ (dollar amount of fee for merchandise)Sales Tax $________ (dollar amount of sales tax) For any merchandise sold for future delivery, the funeral provider shall deposit in a merchandise trust fund an amount of money equal to ________ (deposit as percentage of total cost) % of the total cost.3. The Purchaser agrees to pay for the selected services as follows:[ ]By paying the total case price at the time of purchase, receipt of which is acknowledged.[ ] By the total of payments in accordance with the following schedule.Number of Payments _______ (number of payments)Amount of Each Payment $________ (dollar amount of each payment)One Final Payment of $________ (dollar amount of final payment)First Payment Due ________________ (date of first payment)Payments Will be Made ___________ (monthly/quarterly)If service is performed prior to this agreement being paid in full, the unpaid balance is due at that time.4. Credit Disclosures (Made in Compliance with Federal Law)A. Total Cash Price $________ (dollar amount of cash price)B. Cash Down Payment $________ (dollar amount of down payment)C. Unpaid Balance of Cash Price $________ (dollar amount of unpaid balance)D. Other Charges $________ (dollar amount of other charges)1. Doc. Stamps (on Amount Financed) $________ (dollar amount of stamps)Total Other Charges $________ (dollar amount of other charges)E.Amount Financed (C+D) $________ (dollar amount of amount financed)F. Finance Charge $________ (dollar amount of finance charge)G.Total of Payments (E+F) $________ (dollar amount of total payments)H. Total Sales Price (A+D+F) $________ (dollar amount of total sales price)Annual Percentage Finance Amount Total of Total Sale PriceRate Charge (F) Financed Payments (A+D+F)The cost of your The dollar (C+D) (E+F)credit at a yearly amount theThe amount of The amount youThe total amountrate creditcredit provided will have paid your purchase on will cost you to you or on your after you have credit including behalf. made all your down payment payments as scheduled $____________ (dollar amount of down payment]________ ____________________________(annual percentage $(amount of$(amount of $(amount of$(amount of totalrate)% finance charge) amount financed) total payments) sales price)5. The unpaid balance will be applied first against merchandise until paid in full and then against services.6. Time is of the essence. Until all installments have been fully paid, the funeral provider shall retain title to, and a security interest in, the merchandise. If any default should continue for ______ (number) days or more, the funeral provider, upon _____ (number) days' written notice to Purchaser at the address indicated, may terminate this agreement as to both services and merchandise.7. The funeral provider agrees to provide the above services and merchandise in _________________ (name of county), _____________ (name of state) .8. If, at the time of death of the beneficiary, Purchaser has not paid the full agreement amount, the specified services and merchandise will be performed or provided upon payment to the funeral provider of an amount equivalent to the difference between the full agreement amount and the total payments made by the Purchaser. Alternatively, different services and merchandise may be selected and such different services or merchandise will be performed or provided by the funeral provider upon being paid an additional amount equivalent to the difference between the then prevailing price for such different services and merchandise, and the total payments made by the Purchaser.9. Upon the death of the beneficiary, the Purchaser is designated as the person with whom the funeral provider may consult with questions concerning the funeral services. If the Purchaser is the beneficiary, or predeceases the beneficiary, then ____________________ (name of secondary beneficiary), the _________________ (relationship of secondary beneficiary to beneficiary) of the beneficiary is designated as the person with whom the funeral provider may consult. The funeral provider reserves the right to consult with those individuals having the legal right to control the final disposition of the deceased's remains. The funeral provider shall not be liable to anyone for any decisions made concerning the identity of such persons or actions taken in good faith by the funeral provider pursuant to consultation with such person(s).10. NOTICE TO PURCHASER: You may cancel this portion of this agreement pertaining to services at any time prior to beneficiary's death. If during the life of this agreement, the services are not desired, the contract may be canceled subject to liquidated damages of ______ (liquidated damages percentage during first year) % during the first year, _______ (liquidated damages percentage during second year) % during the second year, and _______ (liquidated damages percentage during third year)% during the third year after the execution of the contract. Subsequently, no liquidated damages are withheld. You may cancel the portion of this agreement which pertains to merchandise within one year from the date of the agreement. Such cancellation entitles you to a _____ (refund percentage)% refund of the money actually paid on the merchandise. Do not sign this agreement before you read it, or if it contains any blank spaces. You are entitled to a copy of the contract you sign. Keep it to protect your legal rights.You, the Purchaser, or your legal representative, may cancel the prearranged funeral service portion of this agreement within ______ (number) days and receive a refund of all funds applicable to the prearranged funeral service without payment of liquidated damages.A copy of this agreement was delivered to, and receipt is acknowledged by each Purchaser.Executed in multiple copies this ________________ (date of execution).___________________(Name of Purchaser)______________________________________________________(Address of Purchaser)Accepted:_________________________(Name of funeral provider)________________________________By: (Name of officer of funeral provider)_______________________(Title of officer of funeral provider)