Enquiry type:
Please complete all the relevent details below.
Enquirer's Full Name:
Enquirer's Email:
Enquirer's Phone Number:
Enquirer's Mobile Number:
Enquirer's Residential Address:
Enquirer's Postal Address:
Please fill out the personal details of the person this enquiry is in relation to eg The deceased or the nominee of the funeral plan.
First Names:
Surname:
Residence:
Date of Birth:
Place of Birth:
If born overseas, year of arrival in Australia:
Date of Death (if applicable):
Place of Death (if applicable):
Usual Occupation:
Retired (Yes or No):
Marital Status:
If widowed, spouse's date & place of death:
Please complete the Parent's details of the deceased or nominee of the funeral plan.
Father's First Names:
Father's Surname:
Father's Occupation:
Mother's First Names:
Mother's Maiden Name:
Mother's Occupation:
Please complete the Marriage details of the deceased or nominee of the funeral plan.
1st Marriage - To Whom (spouse's full name at marriage):
1st Marriage - Place (town/city, state, country):
1st Marriage - Date of Marriage:
2nd Marriage - To Whom (spouse's full name at marriage):
2nd Marriage - Place (town/city, state, country):
2nd Marriage - Date of Marriage:
3rd Marriage - To Whom (spouse's full name at marriage):
3rd Marriage - Place (town/city, state, country):
3rd Marriage - Date of Marriage:
Please provide the full names of the children of the deceased or nominee of the funeral plan.
Living Children - Full Names & Birth Dates:
Deceased Children - Full Names & Birth Dates:
Exectutor's Name:
Do you wish for a burial or cremation? Please select one
Please indicate your religion
How did you hear about us?
Please indicate if the person is/ was in reciept of a pension.
Questions or Comments:
