BRAVURA FINANCE, LLC
450 E. 96th Street, Suite 500, Indianapolis, IN 46240
• Phone: 317-610-3221 - • Fax: 866-554-0262 • www.bravurafinance.com
IMMEDIATE APPROVAL FACT SHEET
(Fax to: Bravura Finance, LLC at 866-554-0262)
APPLICANT INFORMATION
From (Funeral Home/Cemetery) :
Contact Person:
Street Address:
City:
State:
Phone Number:
E-mail Address:
Fax Number:
DEATH INFORMATION
Deceased (As it appears on Insurance Policy):
Social Security #
Date of Birth:
Cause of Death:
-
-
Date of Death:
Natural
Was the death local:
Homicide
Yes
Suicide
Accident
Coroner Case/Pending Death Certificate
No
Who Picked the body up? (Funeral Home) :
Phone:
Are there any other assignments related to this policy(s) that you are aware of?
YES
NO
INSURANCE INFORMATION
Policy #1:
Insurance Co.
Beneficiary:
Relationship:
Policy #2:
Insurance Co.
Beneficiary:
Relationship:
Policy #3:
Insurance Co.
Beneficiary:
Relationship:
Policy #4:
Insurance Co.
Beneficiary:
Relationship:
NOTE: If you have verified this claim, please furnish us the number you called for each insurance company and your contact, if one:
Total Assigned Amount:
Any additional information or requests:
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IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY
Insured/Deceased:
Beneficiary:
Insurance Company:
, and its successors or assigns
Policy Numbers(s):
Funeral Home/Cemetery:
Assigned Amount: $
This Irrevocable Assignment is made between Beneficiary above and the Funeral Home/Cemetery above. In consideration for the Funeral Home/Cemetery
providing services in the burial of the above Insured, said services having been requested and accepted by Beneficiary and/or additional funds having been
advanced to Beneficiary, the undersigned Beneficiary hereby irrevocably assigns to Funeral Home/Cemetery or its assigns the following from the proceeds
of the insurance policy identified above: the above Assigned Amount, plus statutory interest from deceased’s date of death until claim paid and plus
unearned premiums. Beneficiary hereby guarantees the validity and sufficiency of the foregoing irrevocable assignment to the Funeral Home/Cemetery
or its assigns, and Beneficiary further guarantees to warrant title to the policy(s) and defend Funeral Home/Cemetery or its assigns aginst any claims on
the policy(s). Beneficiary hereby irrevocably authorizes said Insurance Company to make payment of the sum specified above, plus statutory intrest and
unearned premiums to the Funeral home/Cemetery or its assigns In addition, Beneficiary hereby irrevocably authorizes said Insurance Company to
give Funeral Home/Cemetery or its assigns any information that it may require regarding said policy(s). Beneficiary hereby appoints Funeral
Home/Cemetery or its assigns as Beneficiary’s Attorney-in-Fact and to act on Beneficiary’s behalf with regard to the collection of, settlement of,
and receipt of proceeds of the said policy(s) or certificates(s), including but not limited to, giving Funeral Home/Cemetery or its assigns the
right to endorse checks and claimant statement forms. Beneficiary further acknowledges that this Assignment may be reassigned to Bravura Finance,
LLC. As such, if for any reason it becomes necessary for Bravura Finance, LLC to proceed against the Beneficiary, it is hereby agreed that the Beneficiary is
liable for all costs of collections, including but not limited to, reasonable attorney’s fees and court costs. In the event such proceeds are not tendered to the
Funeral Home/Cemetery or its assigns within 90 days, the Beneficiary is liable and agrees that the exclusive jurisdiction for legal proceedings hereunder is
the State of Indiana. In the event the policy(s) is not enclosed, I certify that the policy(s) had been lost or destroyed.
Date:
Beneficiary Signature:
Relationship to Deceased:
Telephone #:
Beneficiary’s SS #:
Date of Birth (must be of legal age):
Address:
City:
The foregoing Assignment was executed by (BENEFICIARY NAME)
identification.
NOTARY PUBLIC SIGNATURE:
X
State:
Zip:
, who is personally known to me or who has produced
NOTARY STAMP OR SEAL:
Date:
IRREVOCABLE REASSIGNMENT AND POWER OF ATTORNEY
TO: BRAVURA FINANCE, LLC - 450 East 96th Street, Suite 500, Indianapolis, IN 46240
Phone: 317-610-3221 Fax: 866-554-0262
For value received, the above Funeral Home/Cemetery and its Funeral Director/Owner hereby irrevocably reassigns to Bravura Finance, LLC, 450 East
96th Street, Suite 500, Indianapolis, IN 46240 or assigns, the Assignment made between the above Beneficiary and the above Funeral Home/Cemetery.
The above Funeral Home/Cemetery further appoints Bravura Finance, LLC to act as its Attorney-in-Fact with regard to the collection of, settlement of,
and receipt of the proceeds of the policy(s) or certificate(s) noted above, including but not limited to, the right to endorse checks. The undersigned agrees
that the exclusive jurisdiction for legal proceedings hereunder is the State of Indiana. The above Funeral Home/Cemetery hereby authorizes the above
Insurance Company to issue check(s) for the Assigned Amount directly to Bravura Finance, LLC.
X
Signature of Funeral Home/Cemetery Authorized Representative
Date:
Name of Funeral Home/Cemetery:
The foregoing Assignment was executed by (BENEFICIARY NAME)
identification.
NOTARY PUBLIC SIGNATURE:
X
Name of Funeral Home/Cemetery Authorized Representative
(please print)
, who is personally known to me or who has produced
NOTARY STAMP OR SEAL:
Date:
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