Form 47 Pa – Fill Out and Use This PDF

The 47 Pa form is a crucial document used specifically by funeral directors in Pennsylvania to submit non-contestable preneed claims to the Investors Heritage Life Insurance Company. It compiles the deceased individual's vital information, including Social Security Number, address, and essential details regarding the death, alongside the policy information to process claims efficiently. To ensure the claim is handled smoothly and promptly, filling out this form accurately is essential.

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Form 47 Pa PDF Details

Navigating through the paperwork after the loss of a loved one can be a daunting task, especially when trying to understand specific forms required by insurance companies. One such document, the 47 Pa form, serves a crucial role in the realm of non-contestable preneed claims for those insured by the Investors Heritage Life Insurance Company in Pennsylvania. This form, mandatory to be filled out by a licensed funeral director, encompasses vital information about the deceased, including their name, social security number, policy numbers, and the nature of the policy, whether it be life insurance or an annuity. Additionally, it collects details on the deceased's date and place of birth, alongside the date and place of death, which are essential for processing claims promptly and efficiently. The form also asks for the primary cause of death as listed on the death certificate, location of death, and information about the person arranging the funeral. A unique aspect of this form is its requirement for the funeral director to certify the completion of their services, ensuring that the procedure for claim settlement aligns with the company’s policies and state law requirements. Moreover, any attempt to provide false information or conceal facts is treated as a fraudulent act, highlighting the importance of accuracy and transparency in submitting this form. Knowing these details helps in understanding the form's purpose in the claim process, offering a streamlined way for beneficiaries to receive due benefits without unnecessary delays.

Question	Answer
Form Name	Form 47 Pa
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	pa 47, form 47 pa, pa 47 form, pa form 47pa

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INVESTORS HERITAGE Life Insurance Company

200 CapitalAvenue • PO Box 717 • Frankfort, Kentucky 40602-0717

TollFree(800)422-2011 • Fax:(502)223-6575

PEN N SY LV AN I A

FUNERAL DI RECTOR’S STATEMENT

( Use ON LY for N on - Con t e st a ble Pr e n e e d Cla im s)

INSTRUCTIONS: Mail completed form with the Policy and Obituary (Newpaper Clipping).

Name of Deceased

Social Security Number

Deceased was

Male

Fem ale

Address (P.O. Box - No. - Street)

City

State

Zip Code

Policy Number(s)

Issue Date of Policy(ies)

Type of Policy(ies)

Life Insurance

Annuity

Life Insurance

Annuity

Date of Birth:

Place of Birth:

Date of Death:

Place of Death:

____/____/______

___________________________

____/____/______

_____________________________

(Month / Day / Year)

(City and State)

(Month / Day / Year)

(City and State)

PRIMARY CAUSE OF DEATH as listed on the death certificate filed with the Bureau of Vital Statistics

Where did death occur?		Hospital		Nursing Home		Residence	Other: ________________________
(PLEASE CHECK ONE)		Hospital		Nursing Home		Residence	Other: ________________________
(PLEASE CHECK ONE)


Name of Person Arranging Funeral					Relationship to Deceased			Social Security Number

Address (P.O. Box - No. Street)					City			State		Zip Code

Telephone Number			Were the Policy Proceeds Assigned?				Is the Newspaper Obituary Attached?
(	)				Yes	No		Yes	No

I he r e by ce r t ify t ha t I a m a n a ut hor ize d, lice nse d Fune r a l D ir e ct or ; t ha t t he a bove na m e d I nsur e d is de ce a se d a s se t for t h a bove ; t h a t I w ill/ h a ve pr e pa r e ( d) for fin a l disposit ion t h e body of t h e a bove na m e d pe r son; a nd t ha t I w ill/ ha ve fully pe r for m ( e d) t he fune r a l se r vice s for t he a bove na m e d pe r - son . I hereby cert ify t hat all inform at ion above is t rue and correct t o t he best of m y knowledge and belief. I underst and t hat t he life insurance policy is not cont est able because it was guarant eed issue or because it has been in effect for t wo ( 2) years from t he dat e of issue. The Obit uary ( newspaper clipping) , t he Cert ificat e of Perform ance, if required by st at e law, and t he policy should accom pany t his form . I nvest ors Herit age reserves t he right t o request addit ional inform at ion which it , in it s sole discret ion, deem s necessary t o adj udicat e a claim .

An y pe r son w h o k n ow in gly a n d w it h t h e in t e n t t o de fr a u d a n y in su r a n ce com pa n y or ot h e r pe r son files an applicat ion for insurance or set t lem ent of claim cont aining any m at erially false inform at ion or conce a ls for t he pur pose of m isle a ding, infor m a t ion conce r ning a ny fa ct m a t e r ia l t he r e t o com m it s a fr a udule nt a ct , w hich is a cr im e a nd subj e ct s such pe r son t o cr im ina l a nd civil pe na lt ie s.

Name and Address	Signature of Funeral Director		Funeral Director License No.

	Telephone Number		Email Address
	(	)

	Tax I.D. Number		Date

For m 47 PA Rev. 6/ 2006

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Form 47 Pa – Fill Out and Use This PDF

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