Jackson Funeral Chapels

1.) Are you:

2.) How old are you?

3.) Do you have children?

Yes No How Many

4.) Are you currently:

Employed Retired

5.) Do you have a will that's
been updated recently?

Yes No

6.) Have you ever been
responsible for making funeral
arrangements for someone else?

Yes No

7.) How much would you
expect your funeral to cost?

8.) Are you aware that
prepaid funeral plans exist?

Yes No

9.) Do you have a prepaid funeral plan?

Yes No

9a.) If NO, have you considered
a prepaid funeral plan?

Yes No

10.) Do you currently have life
insurance specifically for your funeral?

Yes No

11.) Does the beneficiary on this
policy know about the policy
and your reason for having it?

Yes No

12.) Which of the following
would you choose for yourself?

13.) Have you made arrangements
for cemetery property for yourself?

Yes No

14.) Have you made arrangments
for the type of burial/cremation
you prefer?

Yes No

15.) Do you have up-to-date
biographical information
and records to help a loved
one with funeral planning?

Yes No Unsure

16.) In the event of your death,
who is responsible for making
your arrangements?

17.) Who is responsible for paying
for your final arrangements?

18.) Are you concerned about
"emotional overspending" by the
person planning your funeral?

Yes No

19.) Does this person know your
preferences including the type of
casket, music, flowers and services?

Yes No

20.) Would it give you peace of
mind to know you've planned
and paid for your own funeral,
sparing your family from the burden?

Yes No

21.) Do you think making your own
arrangements is as important a
personal responsibility as keeping
your insurance and will up to date?

Yes No

Contact Information:

Please share your name and address (optional) if you would like to be contacted about receiving a FREE funeral cost estimate. All information will be kept strictly confidential and used only to help us better serve the families of our community.

Full Name:

Address:

Address (2):

City:

State:

Zip:

Phone:

Fax:

E-Mail