First Name *

Middle Name *

Last Name *

Other Name

Date of birth *

City *

Postal code *

Address *

Children Names

Children Date Of Birth

Children Address

Are you married/divorced/co-habiting or single?

Married/Civil Partnership

Divorced

Co-habiting

Single

1. EXECUTORS *

Relationship
First,Middle and Last names
Date of Birth
Address
Contact number
Email address

2. RESERVE EXECUTORS *

Relationship
First,Middle and Last names
Date of Birth
Address
Contact number
Email address

Do you wish to appoint another executor? *

Yes

No

If Yes, kindly fill up this *

First,Middle and Last names
Date of Birth
Address
Contact Number
Email Address

3. GUARDIANS *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

4. RESERVE GUARDIANS *

First,Middle and Last names
Date of Birth
Address
Contact number
Email Address

Do you wish to appoint another guardian? *

Yes

No

If Yes, kindly fill up this *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

5. LEGACIES

6. REQUESTS & WISHES

7. ORGAN DONATION Have you opted out online?

Yes

No

Please note you will be opted IN to donate organs by law unless you OPT OUT online

8. BURIAL OR CREMATION? Do you have any funeral requests, i.e. burial or cremation, woodland funeral etc.

Burial

Cremation

None

9. TRUSTEE 1 *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

10. TRUSTEE 2 *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

11. RESERVE TRUSTEE *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

Do you wish to appoint another Trustee? *

Yes

No

If Yes, kindly fill up this *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

12. ATTORNEY *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

13. RESRVE ATTORNEY *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

Do you wish to appoint another Attorney? *

Yes

No

If Yes, kindly fill up this *

First,Middle and Last names
Date of Birth
Address
Contact number
Email address

14. BENEFICIARIES

Full name
Address

15. RESERVE BENEFICIARIES

Full name
Address

11. CHARITIESDo you wish to leave anything to any particular Charity?

Yes

No

If yes, which charity?

Would you like to request donations to a particular charity in lieu of flowers?

Yes

No

If yes – which charity

Do you have a prepaid funeral plan?

Yes

No

NEXT