STANDARD INSURANCE PRENEED FUNERAL CONTRACT
Chapter 90, Article 13D, North Carolina General Statutes Governs this Contract
PRENEED FUNERAL ESTABLISHMENT NO.
(“Funeral Home”) sells, and (“Purchaser”)
purchases preneed funeral services, facilities and merchandise for (“Beneficiary”)
whose address is ()
Street address PO Box City State Zip Code Social Security no.
Purchaser acknowledges that he or she understands that: either no goods and services have been selected; or if goods and services were
selected, THE PRICE OF THESE GOODS AND SERVICES IS NOT GUARANTEED.
If applicable, the amount the Purchaser paid to the Funeral Home $ .
It is further understood that a life insurance policy or product is being purchased to fund this contract and that the benefit paid by the life
insurance policy or product may, or may not, be sufficient to pay for the retail costs of the goods and services provided at the time they are
provided. Any life insurance policy or product benefit which has been assigned to the Funeral Home will be applied to the at-need retail cost
of the goods and services provided by Funeral Home.
If this contract is being funded by a previously purchased life insurance policy or product, please complete the following:
Name of Insurance Co. Policy Number Death Benefit
Name of Insurance Co. Policy Number Death Benefit
Name of Insurance Co. Policy Number Death Benefit
Name of Insurance Co. Policy Number Death Benefit
A filing fee of $20.00 must be paid to the NC Board of Funeral Service.
By writing initials, Purchaser acknowledges that if the Purchaser does not receive written notification from the NC Board of
Funeral Service, within 30 days, that the Board has received a copy of this contract, the Purchaser will notify the Board at
1033 Wade Avenue, Suite 108, Raleigh NC 27605-1158 or call (919) 733-9380. The filing of this contract with the NC
Board of Funeral Service is required by law for the Purchaser’s protection. https://ncbfs.org/
By writing initials, Purchaser acknowledges that this sale was made at Funeral Home’s place of business. If this was an off-premises
sale, YOU, THE PURCHASER, MAY CANCEL THIS PRENEED CONTRACT AT ANY TIME PRIOR TO MIDNIGHT OF THE
THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
By writing initials, Purchaser chooses to make this contract revocable or irrevocable. If revocable, Purchaser has the right to
revoke it. If irrevocable, Purchaser does not have the right to revoke it unless Purchaser obtains a court order.
Revocable: Irrevocable:
In accordance with NC Gen. Stat. Sec. 90-210.126(e), if this preneed contract includes a cremation, the purchaser hereby specifies the final
disposition of the cremated remains:
The parties have signed this contract (which includes the provisions on the back) this day of , 20 .
Name of accepting Funeral Home Signature of Purchaser
Address of Funeral Home Address where all mail will be sent
City, State, Zip Code City, State, Zip Code
Signature of Funeral Director or FS licensee, binding Funeral Home to contract Insurance Company and location of home office
FSL NO. FD NO.
Signature of agent accepting application from Funeral Home
Signature of person who sold contract PN sales license no. Policy number if available
Signed and preneed sales license number affixed in presence of
Purchaser at time of sale.
NCBFS PNSI 10/03(rev.03/04)
Original contract remains with Funeral Home preneed file.—Copy to Purchaser—Copy to NCBFS—Copy to Insurance Company
PURCHASE OF INSURANCE
This contract is funded through the purchase of a life insurance policy or product, with premiums equal to the amount of money paid under the
terms of the life insurance policy or product. The insurance policy or product is regulated by the North Carolina Department of Insurance.
Funeral Home agrees that it will not transfer, assign, cash in, encumber or otherwise divert from its intended purpose any policy or product,
which funds, in whole or part, this contract.
USE OF INSURANCE PROCEEDS
Funeral Home will provide services, merchandise, and facilities at Funeral Home’s prices at the time they are provided. If the funding of this
contract is insufficient for payment in full, Beneficiary’s representatives may direct that the death benefit paid by Insurance Company
(Companies) be credited against costs contracted for by the representatives. If not otherwise directed by terms of this contract and the
insurance policy or product, any balance after payment in full shall be paid to Beneficiary’s estate.
REVOCATION
If this contract is revocable, you may revoke this contract at any time prior to the provision of goods and services by the Funeral Home.
Designating Funeral Home to receive the proceeds of the life insurance policy or product does not restrict any right to purchase funeral
merchandise or services in the open market, with the advantages of competition, at any time before Funeral Home delivers the funeral goods
and services.
RIGHTS RESERVED
If a labor dispute, strike, government action, fire, war, epidemic, other disaster, changes in products or other causes beyond its control prevents
or delays Funeral Home from providing the services, facilities or merchandise, Funeral Home may make reasonable substitution of
comparable services, facilities or merchandise, and it will not be liable for inconvenience, delay, emotional upset, pain and suffering, loss or
damage experienced by Purchaser or Beneficiary, their estates, families, legatees, heirs or legal representatives.
SUBSTITUTION OF FUNERAL HOME
If this contract is irrevocable, Purchaser, or, after his or her death, Beneficiary or his or her legal representative, may direct the substitution of
another funeral home to provide equal service, merchandise and facilities at substitute funeral home’s current price.
ENTIRE AGREEMENT
This form, together with the Standard Preneed Statement of Funeral Goods and Services Selected, contains the entire agreement between
Purchaser and Funeral Home and supersedes and integrates all communications and other agreements relating to this subject.
AMENDMENTS
Any changes to this contract must be filed as a new contract, marked “CONTRACT AMENDMENT,” with the NC Board of Funeral Service.
Contract amendment shall not change the irrevocable clause or directive by Purchaser that all funds along with growth be used for the purchase
of funeral services, facilities or merchandise.
EXCLUSION OF WARRANTIES
There are no warranties of merchandise or fitness for a particular purpose extended by Funeral Home. The only warranties, express or
implied, which are granted in connection with the services and merchandise sold under this contract are the express written warranties, if any,
extended by the manufacturers of the merchandise sold, and no warranties are expressed or implied by Funeral Home.
DISCLOSURES BY FUNERAL HOME
All disclosures required by the Federal Trade Commission or other provisions of federal and North Carolina law are attached to this contract.
WARNING
If you have received, are applying to receive, or are receiving public assistance benefits, state and federal laws may restrict the use of the
life insurance policy or product that is purchased to fund this contract. You should carefully review those laws to assure compliance with
those provisions.
NCBFS PNSI 10/03(rev. 03/04)
Original contract remains with Funeral Home preneed file.—Copy to Purchaser—Copy to NCBFS—Copy to Insurance Company
STANDARD PRENEED STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
This statement of disclosure is provided under the requirements of North Carolina G.S. 90-210.25(e). Also, the Federal Trade Commission
requires this form. The Funeral Home is licensed by the NC Board of Funeral Service whose mailing address is 1033 Wade Avenue, Suite 108,
Raleigh, NC 27605-1158. https://ncbfs.org/
With a Standard Preneed Funeral Contract the costs of these goods and services are not guaranteed. They will most likely increase with
inflation. Your selection of goods and services assists you in determining how much your funeral would cost if it were held today.
Funeral Home Preneed Establishment License Number
Name of Beneficiary Date
Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will
explain the reasons in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for
embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we
charged for embalming, we will explain why below.
A. CHARGE FOR PROFESSIONAL SERVICES, FACILITIES AND EQUIPMENT
Basic Services of Funeral Director and Staff and Overhead $
Embalming $
Other Preparation of the Body $
Use of Facilities and/or Staff for Visitation/Viewing $
Use of Facilities and/or Staff for Funeral Ceremony $
Use of Facilities and/or Staff for Memorial Service $
Use of Equipment and/or Staff for Graveside Service $
Transfer of Remains to Funeral Home miles radius $
Hearse $
Limousine or other Family Vehicle $
Other Autos $
Forwarding of Remains to another Funeral Home $
Receiving Remains from another Funeral home $
Direct Cremation $
Immediate Burial $
Additional Services, Facilities, and Equipment (Specify)
$
$ $
$ $
$ $
Total Additional Services, Facilities, and Equipment $
TOTAL SERVICES, FACILITIES AND EQUIPMENT $
B. CHARGES FOR MERCHANDISE
Casket (Specify manufacturer, model, material, color, interior fabric and color) $
Outer Burial Container (Specify manufacturer, model, and material) $
Additional Merchandise (Specify):
$
$ $
$ $
$ $
$ $
TOTAL MERCHANDISE $
C. CASH ADVANCE ITEMS
We charge you for our services in obtaining those items marked with an “X”
Obituary notices $
$
Cemetery charges $
$
Certified copies of death certificate $ $
Flowers $ $
Crematory charges $ $
TOTAL CASH ADVANCE ITEMS $
D. NC SALES and USE TAX $
TOTAL CASH ADVANCE ITEMS AND NC SALES and USE TAX $
E. OTHER (Specify) $
TOTAL FUNERAL SERVICE (A+B+C+D+E) $
Disclosures: North Carolina law does not require the purchase of any funeral goods or services (except a cremation container is required for cremations). If any
other legal, cemetery, or crematory requirement has required the purchase of any of the items listed above, we will explain the requirement below:
Reason for embalming
By writing initials, Purchaser acknowledges that a current casket and outer burial container price list was shown prior to discussing prices. A current
General Price List was given to the purchaser for retention.
Executed at , NC Date
Signature of Purchaser
Signature of preneed licensee License Number
NCBFS SG&S 10/03(rev.03/04) Original remains with Funeral Home preneed file. -Copy to Purchaser -Copy to NCBFS -Copy to Financial Institution or Insurance Company.
