This information will be used to populate your Funeral Trust form.
Proposed Insured
This information refers to the Medicaid recipient or their spouse. If requesting a Funeral Trust for both, complete 2 different forms.
Full Name
*
Sex
A
M
B
F
Address
Date of Birth
*
/
/
City/State/ZIP
Age
SSN
*
Email
*
Phone Number
Owner (If other than Proposed Insured)
Only complete this section if the Medicaid recipient is not able to verbally acknowledge their need for this request
Full Name
Sex
A
M
B
F
Address
City/State/ZIP
Date of Birth
/
/
Age
SSN
Relationship to Insured
Email
Plan and Payment Information
Funding Option
A
Check (Only check here if you will be mailing a paper check or cashier's check to fund the burial
B
EFT Payment (By selecting this option we will do an ELECTRONIC FUNDS TRANSFER from your account)
Amount you are putting into the burial fund
Bank Account Information
(Only complete if EFT Payment is selected)
Bank Name
*
Account Type
*
A
Checking
B
Savings
Routing Number
*
Be sure to double check the routing number & include preceding zeros. This number is always 9 digits.
Account Number
*
Be sure to double check the account number. Processing will be delayed if the account number is not an exact match.
Account Owner
*
Draft Date
*
/
/
Use today's date if you would like the funds withdrawn as soon as possible.
I authorize the carrier to make a one-time withdrawal from my bank account to fund this life insurance policy:
*
If being signed by POA (Power Of Attorney), POA documents will need to be emailed to us at Support@EZMedicaidApps.com
Beneficiary & Trust Information
Please submit any additional information on a separate sheet
Trust Assignment: I authorize the carrier to make a one-time withdrawal from my bank account to fund this life insurance policy:
*
Applicant Signatures
Signed at (City, State)
*
Signature of Proposed Insured
*
If being signed by POA (Power Of Attorney), POA documents will need to be emailed to us at Support@EZMedicaidApps.com)
Date Signed
*
MM/DD/YYYY
Signature of Proposed Insured (If other than the Proposed Insured)
Only complete this section if the Medicaid recipient is not able to verbally acknowledge their need for this request
Signature of Proposed Insured
Only complete this section if the Medicaid recipient is not able to verbally acknowledge their need for this request
Signed at (City, State)
Date Signed
MM/DD/YYYY
Proxy
Proposed Owner’s Signature
*
Date Signed
*
MM/DD/YYYY
Summary and Explanation Signature
Assignor Signature(s)
*
(If being signed by POA (Power Of Attorney), POA documents will need to be emailed to us at Support@EZMedicaidApps.com)
Date Signed
*
MM/DD/YYYY
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