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 Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Gender Assigned at Birth
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Relationship to Beneficiary (Intended Decedent)
*
Self
Spouse
Parent
Child
Other
Who is this plan for?
(Beneficiary / Intended Decedent Information)
Full Legal Name
*
Mr.
Mrs.
Ms.
Prefix
First Name
Middle Name
Last Name
Suffix
Other Full Names
Only complete this field if beneficiary has different legal, married, or commonly used names.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Assigned at Birth
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Social Security Number (SSN)
*
Enter 999-99-9999 if beneficiary was never issued a SSN or if SSN is unknown.
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
*
Please Select
Married
Married but Separated
Married Simultaneous Death
Widowed
Divorced
Never Married
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 Name
Middle Name
Last Name (include birth/maiden name, if applicable)
Suffix
Race (Select all that apply)
*
White
Black
American Indian
Asian Indian
Chinese
Filipino
Japanese
Other Asian
Native Hawaiian
Samoan
Guamanian/Chamorro
Other Pacific Islander
Unknown
Other
Hispanic/Latio Origin
*
Yes
No
Unknown
If Yes, select specific origin
Haitian
Mexican
Puerto Rican
Cuban
Other Hispanic
Highest Level of Education
*
Please Select
8th Grade or Less
9th Through 12th Grade; No Diploma
High School Graduate or GED Completed
Some College Credit, but No Degree
Associate Degree
Bachelor’s Degree
Master’s Degree
Doctorate or Professional Degree
Unknown
Veteran Status (US Armed Services)
*
Yes
No
Unknown
Beneficiary's Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Father's/Parent's Legal Name at Birth
*
First Name
Middle Name
Last Name
Suffix
Mother's/Parent's Legal Name at Birth (Last Name Prior to Marriage)
*
First Name
Middle Name
Last Name
Suffix
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 ($12 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 ($12 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 full
Three (3) months
Six (6) months
Nine (9) months
Twelve (12) months
Eighteen (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 Payments
Coupon Books
Global Travel Protection
Travel with total peace of mind. By adding Global 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 Global Travel Protection to your plan for a single, one-time payment?
*
Yes (+$495)
No
Submit
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