Pre-Need Establishment Registration Form - Mississippi Secretary Of State (Page 4 of 5) in pdf

Pre-Need Establishment Registration Form - Mississippi Secretary Of State Page 4

Pre-Need Establishment Registration Form

Page Four

Attestations

(initial where applicable):

________ I understand that I have an obligation to provide a copy of the Pre-need contract and/or insurance

policy to the insured within 15 days of issue.

________ I have provided a list of the merchandise and services which are applied or contracted for in the pre-

need contract and all relevant information concerning the price of the funeral services, including an indication

that the purchase price is either guaranteed at the time of purchase or to be determined at the time of need.

________ I have provided all relevant information concerning what occurs and whether any entitlements or

obligations arise if there is a difference between the proceeds of the life insurance policy and the amount

actually needed to fund the pre-need contract.

________ I have provided any penalties or restrictions, including, but not limited to, geographic restrictions or

the inability of the provider to perform, on the delivery of merchandise, services or the pre-need guarantees.

________ I understand that our organization must be able to lawfully provide merchandise or services at the

time of a person’s death.

________ I have verified that pre-need funds placed in a trust account will be deposited in a financial institution

that is chartered and authorized to do business in Mississippi.

I certify that all information provided herein is true and correct to the best of my knowledge.

__________________________________________________________________________________________

Date

Signature of President or Authorized Officer

_________________________________________________________________________________________

Name (PRINT)

__________________________________________________________________________________________

Title (PRINT)

(For initial filing, enclose $250.00 filing fee made payable to the Mississippi Secretary of State’s Office. The

payment, Registration Forms and all attachments should be mailed to Mississippi Secretary of State’s Office,

Pre-Need Registration, P.O. Box 136, Jackson, MS 39205-0136.)

Rev. 05/2004

Pre-Need Establishment Registration Form - Mississippi Secretary Of State Page 4