* - Mandatory
Please provide the following information on the deceased
   
FirstName*  
   
Last Name*  
   
Date of Death
   
Cause of Death
   
Address
   
Address Line2(Apt,Bldg,Suite)
   
City
   
Province
   
Postal Code
 
Please provide the following information for yourself
   
FirstName*  
   
Last Name*  
   
Address
   
Address Line2(Apt,Bldg,Suite)
   
City
   
Province
   
Postal Code
Phone Number*    
   
Your relationship to the deceased
 
Email Address
   
Is there a Funeral assignment?
   
What is the name of the funeral home?
   
Is there any additional information you'd like provide regarding this claim?
 
Please wait while the claim is being submitted. It may take few minutes.