Beta Capital Corp.
Toll Free: (800) 430-7935
Phone: (757) 488-6960
Fax: (877) 375-9118
4007 Seaboard Ct., Suite 1
Portsmouth, VA 23701
www.betacapitalcorp.com
ADVANCE REQUEST
INSTRUCTIONS:
1. It is the funeral director's responsibility to identify and have all beneficiaries complete and sign all documents
required by the applicable insurance company(ies) in order to obtain funding through Beta Capital Corp. NOTE: We
request that all policy beneficiaries also sign your funeral contract to establish each beneficiary's liability to
your funeral home.
2. Write or type the information needed and sign and date this Advance Request at the bottom.
3. Fax this Advance Request to Beta Capital Corp. A claims representative will immediately verify that the insurance
policies are unencumbered by loans, unpaid premiums, pledges, etc. You will be called with that information as
soon as it is available.
4. Our office will fax you a copy of the claim form or claimant's statement required by the applicable insurance
company(ies), or instruct you in regard to the claim form in group insurance cases.
5. Have the claim form and the Assignment/Reassignment completed, executed, and notarized, where applicable.
Next, fax these documents to Beta Capital Corp., along with a copy of the funeral contract, signed by all assignees.
Recognizing your need for confidentiality, our office will not share a copy of your funeral contract with anyone other
than the applicable insurance companies.
6. It is not necessary to have a death certificate in hand to receive payment on your Advance Request. Beta Capital
Corp. will pay your funeral home on our Reassignment after completion of the above steps. In normal
circumstances, after our receipt of the above-detailed faxed copies, payment to you will be made the same day, or
within 24 hours. You may choose payment by check by Fed Ex next morning delivery, or by wire transfer into your
bank account, at no cost to you.
7. Immediately upon receipt of your funds, return all the originals of the above-required documents
to Beta Capital Corp., including a certified copy of the death certificate, if available. If you do not have
the certified death certificate when you receive payment from our office, please return all the other documents, and
send us the death certificate when you receive it.
8. Beta Capital Corp. will deduct the fee from your check or wire transfer. You will receive an itemized statement
with your payment.
9. The undersigned agrees and understands that in the event the amount funded is paid directly to the Funeral Home
from insurance proceeds either by the insurance company or by the beneficiary, the Funeral Home is to forward the
monies due Beta Capital within ten (10) days of receipt, or you shall be held in default. Should the undersigned
default under these terms, and this account is referred to an attorney for collection, then the undersigned promises
and agrees to pay all collection costs including attorney fees of 33⅓ % of the principal amount due and owing
when turned over for collections and does further agree to pay interest on the unpaid balance at the rate of
1½% per month (18% per annum) from the date that said monies became due and payable.
Amount of Advance Requested: $
Request Date:
For the Funeral of:
Social Security No:
Date of Birth:
Date of Death:
Place of Death:
Cause of Death (check one):
Natural ❑
Suicide ❑
Homicide ❑
Accidental ❑
Do you have the final death certificate?
Yes ❑
No ❑
Is it pending?
Yes ❑
No ❑
If Beneficiary is a spouse are they:
Married ❑
Separated ❑
Divorced ❑
Common law ❑
Name of other funeral home or cemetery taking an assignment on this case:
Insurance Company
Policy Number
Face Amount
Beneficiary/Relationship
Name of Funeral Home:
Signature of Funeral Director:______________________________________________________ Date: _______________
PRINT NAME AND SIGN