Pre-Arrangement Form

Pre-Arrangement Form

If you would like to pre-arrange cremation services with Clearview, please complete the form below at your convenience. Once received, we’ll prepare your personalized pre-need contract and promptly follow up to collect signatures and arrange for payment. Our goal is to make this process as simple, secure, and stress-free as possible. If you are completing this on behalf of a loved one who is expected to pass soon (for example, someone currently in hospice or in the hospital), please call or text us directly at (855) 704-3344 instead of filling out this form so we can assist you right away and make the process as seamless as possible.
Who is filling out this form?

(Purchaser Information)
Full Legal Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Gender Assigned at Birth*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Beneficiary (Intended Decedent)*

SelfSpouseParentChildOther
Who is this plan for?

(Beneficiary / Intended Decedent Information)
Full Legal Name*

First NameMiddle NameLast NameSuffix
Other Full Names
Only complete this field if beneficiary has different legal, married, or commonly used names.
Date of Birth*

MonthDayYear
Date
Gender Assigned at Birth*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Beneficiary's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number (SSN)*
Enter 999-99-9999 if the beneficiary was never issued an SSN, the SSN is unknown, or if you prefer not to provide it at this stage. Please note: We will need the SSN when services are provided after a passing, as part of our responsibility is to notify Social Security.
State of Birth (or province/county if born outside U.S.)*
City of Birth*
Occupation (Please do not enter "Retired")*
Enter the primary occupation the individual held during their working years. Please do not enter “Retired”.
Business or Industry*
Associated with Occupation
Marital Status of Beneficiary*
Married Simultaneous Death refers to a situation where both spouses pass away at the same time or under circumstances where the order of death is uncertain.
Surviving Spouse Full Name

First NameMiddle NameLast Name (include birth/maiden name, if applicable)Suffix
Race (Select all that apply)*

WhiteBlackAmerican IndianAsian IndianChineseFilipinoJapaneseOther AsianNative HawaiianSamoanGuamanian/ChamorroOther Pacific IslanderUnknownOther
Hispanic/Latio Origin*

YesNoUnknown
If Yes, select specific origin

HaitianMexicanPuerto RicanCubanOther Hispanic
Highest Level of Education*
Veteran Status (US Armed Services)*

YesNoUnknown
Father's/Parent's Legal Name at Birth*

First NameMiddle NameLast NameSuffix
Mother's/Parent's Legal Name at Birth (Last Name Prior to Marriage)*

First NameMiddle NameLast NameSuffix
Death Certificates

Each Clearview Cremation package includes one certified death certificate at no additional cost. If you would like additional copies, please enter the number below.
OPTIONAL: Additional Long-Form Death Certificates ($15 each)
These include the cause of death and Social Security number, which are often needed for banks, insurance, pensions, and other official matters.
OPTIONAL: Additional Short-Form Death Certificates ($15 each)
These do not include cause of death or Social Security number and are typically used for personal records or non-financial matters.
Payment Preferences
Duration of Payment*

Upfront in fullThree (3) monthsSix (6) monthsNine (9) monthsTwelve (12) monthsEighteen (18) months (+$100 long-duration fee)Twenty-four (24) months (+$100 long-duration fee)
Desired Method of Payment*

Bank Account Auto-Debit (Suggested)Credit/Debit Card PaymentsCoupon Books
Comprehensive Travel Protection
Travel with total peace of mind. By adding Comprehensive Travel Protection, you are covered whenever you are more than 75 miles away from your primary residence. This one-time membership ensures your loved ones will never face unexpected expenses or complicated logistics during a difficult time. Would you like to add Comprehensive Travel Protection to your plan for a single, one-time payment?*

Yes (+$495)No
Click Here to Learn More
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Last Four Digits of SSN*
Should be Empty:

Pre-Arrangement Form

Who is filling out this form?

Who is this plan for?

Death Certificates

Payment Preferences

Comprehensive Travel Protection