| Contact Information |
Full Name:
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Street Address: |
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City: |
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Province: |
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Postal Code: |
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Phone #: |
(xxx-xxx-xxxx) |
Cell #: |
(xxx-xxx-xxxx) |
Email Address: |
(xxx@domainname.com) |
Best time to call: |
(please include am or pm) |
Best time to visit: |
(please include am or pm) |
| Questionnaire |
How old are you?
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25-40
41-65
66-85
86 or older |
Are you currently? |
Employed
Retired |
| Do you know what your Canada Pension Plan Death Benefit will be? |
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Yes
No |
| Have you ever been responsible for making Funeral/Cemetery Arrangements? |
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No
In the last 12 months?
13-24 months?
Over 24 months ago? |
| Are you aware that prearranged funeral/cemetery plans exist |
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Yes
No |
| Have you ever considered pre-paying for a pre-arranged funeral/cemetery plan |
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Yes
No |
| Given you knowledge of funerals, what might you expect to pay for a funeral? |
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$1000-$2000
$2000-$4000
$4000-$6000
$6000-$8000
over $8000
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| How important is the proximity of the funeral home or cemetery? |
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Very Important
Somewhat Important
Not Important at all |
| How often would you visit that cemetery? |
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| Are you going to be responsible for making Funeral/Cemetery arrangements for a loved one? |
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Yes
No |
| Which of the following would you choose for yourself |
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Burial
Cremation |
| Have you made Funeral Arrangement plans? |
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Yes
No |
| Have you made Cemetery Arrangements? |
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Yes
No |
| If you answered yes to the above question, which Funeral Home have you chosen? |
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| If you answered yes to question 12, which Cemetery have you chosen |
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| Would like free information on: (please select as many as you wish) |
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Cemetery Arrangements
Funeral Choices
Funeral Benefits
Cremation Options |
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We would like to inform you that. In accordance with Canada's Personal Information Protection and Electronic Documents Act, the personal information we collect from you will only be used for the purpose of creating and maintaining a responsible relationship with you and provide you with the information you request. This information shall be kept confidential and shall not be disclosed to any unauthorized third party or used for any other purpose without your consent.
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