Funeral Home Authorization

Complete this form to authorize Aegisant Insurance Services agents to sell preneed arrangements at your funeral home.

indicates a required field

Funeral Home Information

Funeral Home Name

FD License #

Tax ID / EIN

Sales Tax Rate (%) Enter percentage, e.g. 7.25 for 7.25%. Enter 0 if no sales tax applies.

Representative / Owner Name

Title

Street Address

City

State

ZIP

Phone

Fax

Create Your Account

Email This will be your login email.

Password

Confirm Password

Price Lists & Package Information

Please upload your current pricing documents.

General Price List (GPL) PDF or Word document

Casket Price List PDF or Word document

Package Forms (Optional) You may upload multiple files. PDF or Word documents.

I agree to inform Aegisant Insurance Services/Gregory Brack Agency of any changes to pricing. I understand it may take up to 10 working days to update the digital funeral packages once pricing change notification has been made. I agree to continue to accept preneed funeral arrangements at the previous agreed pricing while updates are being made.

Authorization

I authorize Aegisant Insurance Services/Gregory Brack Agency and their agents to solicit and sell preneed funeral arrangements funded by Great Western Insurance Company products for our funeral home location(s).

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