Application form

Step 1 of 11

Plan Creation Form

A/PA No:

Select your plan(Required)

Single

Joint

DUO

Charity of choice

Personal Info

Name(Required)

Prefix First Last

Will be used as the main email for the account

Phone(Required)

Nationality(Required)

Religion(Required)

Passport Number(Required)

NIE/TIE/DNI No:(Required)

Date of birth(Required)

DD slash MM slash YYYY

Address(Required)

Street Address Address Line 2 City Potstcode Country

Applicant 2 Personal Info

Name(Required)

Prefix First Last

Phone

Nationality(Required)

Religion(Required)

Passport Number(Required)

NIE/TIE/DNI No:(Required)

Date of birth(Required)

DD slash MM slash YYYY

Select Plan

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Which Plan...

Clarity

Tranquility

Serenity

Unity

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Applicant 2

Clarity

Tranquility

Serenity

Unity

Applicant 1 - Plan

Please fill out other fields.

Applicant 2 - Plan

Please fill out other fields.

Payment options

Payment(Required)

In Full

Monthly

Over how many years?(Required)

Please enter a number from 1 to 10.

Max: 10 years (Or 5 years for Unity plan)

Total

Price: 0,00 €

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Applicant 1 Deposit

Clarity

Tranquility

Serenity

Unity

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Applicant 2 Deposit

Clarity

Tranquility

Serenity

Unity

Deposit Total

Price: 500,00 €

Monthly Total

Price: 0,00 €

Do you wish to create a Children’s Plans for either related children or grandchildren?

Yes

If ticked, we will contact you directly to discuss and arrange.

Next of kin

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City Potstcode Country

Phone(Required)

Date of birth(Required)

DD slash MM slash YYYY

Relationship to Plan Holder:(Required)

Are they aware that they are recorded as a next of Kin:(Required)

Yes

Does applicant 2 have a different next of kin?(Required)

Yes

Applicant 2 Next of kin

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City Potstcode Country

Phone(Required)

Date of birth(Required)

DD slash MM slash YYYY

Relationship to Plan Holder:(Required)

Are they aware that they are recorded as a next of Kin:(Required)

Yes

10-Year Legacy Refund Commitment Beneficiary Details

The 10-Year Legacy Refund Commitment allows the Plan fee to be refunded to the Plan Holders Nominated Beneficiary/ies. The funds will be released to them on presentation of the original certificate and them reaching the age of 18.

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City Potstcode Country

Phone(Required)

Date of birth(Required)

DD slash MM slash YYYY

Relationship to Plan Holder:(Required)

NIE/TIE/DNI No:(Required)

If you do not have one, write N/A

Nationality(Required)

Is there a second beneficiary?(Required)

Yes

Note: Beneficiaries must have reached the age of 18 to receive the Legacy Refund

2nd 10-Year Legacy Refund Commitment Beneficiary Details

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City Potstcode Country

Phone(Required)

Date of birth(Required)

DD slash MM slash YYYY

Relationship to Plan Holder:(Required)

Nationality(Required)

NIE/TIE/DNI No:(Required)

If you do not have one, write N/A

Note: Beneficiaries must have reached the age of 18 to receive the Legacy Refund

Additional Information

Special requests / Additional Information

Consent

Consent(Required)

I/We Agree to purchase the Elysium Funeral Plan(s) as detailed in this Plan Creation Form(Required)

Consent(Required)

I/We understand that the Plan documentation and a copy of the Terms & Conditions relating to this plan will be sent to me and that I have 30 days from the day of signing this Plan Creation Form in which to cancel for a full refund.(Required)

Signature(Required)

Applicant 2 Signature(Required)

Payment

Pay offline

I would prefer to pay offline

Credit Card

Name

This field is for validation purposes and should be left unchanged.

What to Do:

Clarity

Tranquility

Serenity

Unity

Bespoke

Elysium Privileges

FREE Will

Your protection

FREE Trees

FREE Funerals

FREE charity donations

FREE entry to win back fee

Your wishes

Elysium Aftercare

we are different

Plan Creation Form

Plan Creation Form

Personal Info

Applicant 2 Personal Info

Select Plan

Payment options

Next of kin

Applicant 2 Next of kin

10-Year Legacy Refund Commitment Beneficiary Details

2nd 10-Year Legacy Refund Commitment Beneficiary Details

Additional Information

Consent

Payment

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