SERENITY🍂 Asistencia Funeraria para la Familia y Mascotas

Holder & Co-Holder Info

Holder information

First Name

Middle Name

Last Name

Birthdate

Age

Birth Country

Gender

Marital Status

Language

Address

City

State

Address Street 2

Zip Code

Country

Phone

Other Phone

Beneficiary

Co-Holder Information

First Name

Middle Name

Last Name

Phone

Business Phone

Address

City

State

Address Street 2

Zip Code

Country

Beneficiary

Plan & Beneficiaries

AMERICA PLAN

(2 beneficiaries)

USA o LATAM

$39

SERENITY PLAN

(4 beneficiaries)
USA o LATAM

$49

SERENITY PLUS PLAN

(8 beneficiaries)

USA + LATAM

$69

Please List of beneficiaries

1

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

2

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

3

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

4

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

5

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

6

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

7

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

8

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

9

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

10

First Name

Middle Name

Last Name

Birthdate

Age

Relationship

Mobile Phone

Nationality

City

State

Residence

Pets

Number of pets

Payment

Payment Method:

Type of Plan:

America

Serenity

Serenity Plus

Coupon

	Riders \| Add-ons	Price
	Repatriation	$10
	9th Beneficiary	$10
	10th Beneficiary	$10
	2nd Pet	$9
	3rd Pet	$8
	4th Pet	$7

Price

Fee

Rider

Sub Total

Coupon

Amount Due Today

Payment Date

Next Payment

Agent Code

Agent Name

Agent Email

Observations

Medical Questions

Has any beneficiary been diagnosed with a terminal illness or suffer from an illness that could cause imminent death? (Included covid-19)

Yes

Is any beneficiary currently hospitalized or in hospice (palliative care)?

Yes

Does any of the beneficiaries suffer or had suffered or has been diagnosed from any of the following illnesses or medical conditions? Cancer in remission within the past 5 years, renal insufficiency, dialysis, stroke, cardiovascular accident, arteriosclerosis, or organ transplant in the past 3 years, or any other medical condition in which a medical professional has diagnosed you with a terminal illness, or any other condition that may provoke the imminent death of the beneficiary in the next 18 months.

Yes

Share 1	Price	Payment Date
Share 2	Price	Payment Date
Share 3	Price	Payment Date

Holder & Co-Holder Info

Holder information

Co-Holder Information

Plan & Beneficiaries

1

2

3

4

5

6

7

8

9

10

Pets

1

2

3

4

Payment

Instrucciones para pagos por ZELLE.

Medical Questions