Funeral Home Authorization

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

Funeral Home Information

Funeral Home Name *

FD License #

Tax ID / EIN

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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