Moeller Funeral Home
104 Roosevelt Road
Valparaiso, IN  46383
(219) 462-0535
 Kosanke Funeral Home
105 East Indiana Avenue
Kouts, IN  46347
(219) 766-2224

Wanatah Funeral Chapel
309 North Main Street
Wanatah, IN  46390
(219) 733-2313
 Angelcrest Cemetery
Highway 49 and 600 North
Valparaiso, IN  46383
(219) 531-8690

Pre-Arranged Funeral Agreement

AGREEMENT - The provider agrees to provide the funeral service as specified on reverse side in consideration of a funeral trust and/or an assignment of death benefits of life insurance or annuity coverage with an initial face amount at least equal to the now-current total retail price for the items selected.

PRICE GUARANTEE - The prices shown on the reverse side are the now-current retail prices and are illustrated for the sole purpose of establishing the amount required to fully fund this agreement.  At the time the goods and services are provided, the then-current retail prices will be charged.  If the retail prices then exceed the death benefits assigned and the guarantee is not limited as described below, the provider will supply and perform as specified and accept the available assigned death benefits as payment in full.  If the death occurs at a location further than a 25-mile radius from provider's address, there may be an additional cost for transportation not anticipated at the time of this agreement.

EXCESS BENEFITS - If the actual death benefits exceed the then-current retail prices, the excess benefits may be retained by the provider.  However, if the purchaser is an Indiana Medicaid recipient, then the provider may claim benefits only up to the amount of goods and services provided and any excess benefits will be paid to the estate of the recipient or the Indiana Office of Medicaid Policy and Planning, or according to prevailing laws at that time.  

FREEDOM OF CHOICE - This agreement may be transferred at any time prior to the performance by the provider.  Charges are only for those items that are used.  If required by law to use any items, the provider will explain the reasons in writing.  The purchaser, during his/her lifetime and thereafter, the purchaser's next of kin or legal representative retains the right to select the provider that will supply the services and merchandise or location;  however, if an alternate provider or location is so selected, this agreement shall become null and void and the original provider agrees to then relinquish all claims to the funeral trust and/or life insurance or annuity proceeds.  After written notice has been received and any applicable transfer fees have been paid to the original provider.

CANCELLATION - The purchaser may terminate this agreement within 30 days of execution, however, the cancellation of this agreement does NOT cancel the life insurance or annuity, which may only be canceled according to the terms of the life insurance or annuity.  The funding insurance or annuity coverage also may be canceled within 30 days.  After 30 days, ownership rights are controlled irrevocably by the Trustees. 

LIMITATION OF GUARANTEE -  If the purchaser funds this agreement with limited benefit life insurance or annuity coverage and the funeral recipient dies during the limited benefit period or with life insurance or annuity with an initial face amount less than the now-current retail prices for the items selected, or if the purchaser funds this agreement with a previously issued insurance policy (one not issued in conjunction with this contract) this contract is guaranteed only to the extent of available proceeds at the time of death of the insured, or the party responsible for the funeral must pay any difference between the available death benefits and the then-current prices or delivery of services and merchandise may be reduced to the extent of funds actually received at the time delivery is made.

OBLIGATIONS -  This agreement shall be void unless the purchaser presently applies for and has issued the funeral trust and/or life insurance or annuity coverage, pays all premiums due, fully maintains the cash values intact, and the death benefits thereof are assigned to the provider, and when funding this contract with a previously issued insurance policy, ownership of such policy must also be irrevocably assigned to the provider.

NON-GUARANTEED CASH ADVANCES -  Cash advances are amounts established to help pay for items whose costs are not guaranteed.  At the time of delivery, funds available shall be applied by the provider to the prepaid services and merchandise and cash advance items in the same proportion as initially funded.  If the available proportioned amount does not meet the current cost of the cash advance item(s), those responsible for payment for funeral expenses must pay the difference.

SUBSTITUTION -  If the provider is unable to perform due to the unavailability of merchandise or other factors beyond its control, it may substitute merchandise of like or better quality in lieu of the merchandise selected.  If the provider is unable to perform or another provider is chosen, the life insurance or annuity proceeds may be available for use with that provider;  however, prices and guarantees may be at the discretion of that alternate provider, according to prevailing laws at the time.

PURCHASER ACKNOWLEDGMENTS -  By his/her signature on this agreement, the purchaser acknowledges receipt of a completed copy of this agreement and acknowledges that a current General Price List, a current Casket Price List, a current Outer Burial Container Price List, and each of said documents, were made available to him/her prior to his/her selection of services and merchandise.  The purchaser further acknowledges an understanding of the irrevocable nature of the assignment of ownership rights executed with this agreement.

ASSIGNMENT -  In fulfillment of the consideration required under this agreement, the purchaser hereby revocably assigns to the provider the right to receive death benefits contingent upon the performance by the provider as specified on the statement of goods and services.  This assignment shall exist even though an insurance beneficiary is named.  It notifies the trustee named on the irrevocable assignment and directs them to pay benefits to the assigned provider up to its legitimate interests as described above.  In addition, the purchaser must execute a separate and irrevocable assignment which assigns the balance of the ownership rights to the Trustee, after 30 days, until the death of the insured.  The funding insurance or annuity will thereby be held in trust and the purchaser may not borrow against, pledge, withdraw, impair its cash values, or receive a refund of premiums paid.  Neither purchaser nor provider may assign this agreement without the written consent of the other.

COMPENSATION -  The provider will or may receive compensation as the result of the sale of any insurance or annuity policy sold to fund this agreement.  The provider will or may receive an amount not to exceed 10% of the provider's original cost of all services and merchandise (total funeral home charges) within 10 days after this agreement becomes irrevocable, when funded by a cash deposit to a funeral trust fund held by a bank.

SALE BY AGENT -  This agreement may be executed by an agent authorized by the provider to act in this exclusive capacity, however, the provider is the only entity authorized to perform.  The provider is responsible and liable for the veracity and competency of the agent.

INCAPACITY OF PROVIDER -  If provider is incapable of performing its obligations under this agreement for any reason, provider shall notify the Board, Indiana State Board of Funeral and Cemetery Service, and purchaser in writing after provider becomes incapable of performing its obligations under this agreement.  Purchaser shall have 30 days from the date such notice was mailed to select and designate a new provider to become the beneficiary of the trust.  If purchaser fails to select a  provider, the Board shall be permitted to change the beneficiary of the trust by naming a new provider as the new beneficiary.

ADDRESS CHANGE -  Purchaser agrees to notify the provider of any change of address of the purchaser or insured.

INVALIDITY -  If any provision hereof is for any reason declared invalid or illegal, such action shall not affect the remaining provisions hereof which shall remain in full force and effect.