Form H1238-A, Verification of Pre-Need Information

Effective Date: 12/2009


Word: H1238-A.doc

PDF: H1238-A.pdf


Updated: 12/2009


To request information about an applicant/recipient's burial resources.


When to Prepare

The worker sends Form H1238-A to funeral homes or insurance companies to get pertinent information about burial resources.

Number of Copies

The worker completes an original, typed or legibly handwritten. He records the date he sent the form on Form H0007-A, Financial Services Activity Record, or prepares a copy of Form H1238-A for the case record. (Follow regional instructions.)


The worker sends the original to the appropriate funeral home or insurance company and keeps the duplicate (if any) in the case record. Attach Form H0003, Authorization to Furnish Information, (signed by the applicant, recipient or responsible person) to the original.

Form Retention

If a copy is made for the case record, keep the copy for three years.

Detailed Instructions

To — Enter the name and address of the funeral home or insurance company

From — Enter the worker's name and local office mailing address.

ApplicantIRecipient Information — Enter the name of the applicant or recipient, the contract or insurance policy number(s), if known, and any pertinent comments.

The worker signs the form and enters the date and his telephone number. A funeral home or insurance company representative completes the other items on the form.
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