Burial Insurance Assignment of Proceeds Form

Insurance Company Name Policy Number Insured Name Beneficiary Name Relationship to Insured

Funeral Home Information

Funeral Home Name Funeral Home Address Funeral Director Name Phone Number

Assignment of Proceeds

I hereby assign the proceeds of the above-referenced insurance policy, in an amount not to exceed the funeral expenses, to the named funeral home for payment of funeral, cremation, or burial services rendered for the insured.

Amount Assigned

Beneficiary Signature

Date

Funeral Director Signature

Date