First Death Application

(for couples taking out a plan each please submit 2 separate applications)
[group joint-application]

Second Person

Your Name (required)

Date of Birth (required)

Passport number (required)

Address (required)

Phone Number (required)

e-mail address (required)

Mother's Name (required)

Father's Name (required)

Next of kin (required)

Next of kin telephone number (required)

Emergency Contact

Emergency Contact Name (required)

Emergency Contact Relationship (required)

Emergency Contact Phone Number (required)

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Plan

Plan: Bronze Plan 2595€--2595Silver Plan 3195€--3195Gold Plan 3995€--3995Emerald Plan 3995€--3995Repatriation Plan 7995€--7995

Payment Type: FullMonthly Instalments

[group group-24months-dd]
Deposit: —Please choose an option—595--5951000--1000

Remaining Balance:

Payment Term: —Please choose an option—12--1224--24

Monthly Repayments:

Direct Debit

By signing this mandate form for your White Doves Funeral Plan, you authorise (A) Grupo MCortexx SL to send instruction to debit your account and (b) your bank to debit your account in accordance with the instruction from Grupo MCortexx SL. You are entitled to a refund from your bank after your account has been debited and you can request your bank not to debit your account up until the day on which the payment is due. Please contact your bank for detailed procedures in such a case.

Name

Address

Swift Bic / Sort Code

IBAN / Account Number

Date

Signature

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YOUR DECLARATION

Applicant 1

I/We hereby agree to purchase a funeral plan from White Doves Funeral Planning as specified above. On purchasing my funeral plan, I accept that my personal details will be held for the purpose of administering the plan and will be shared with the relevant individuals and funeral directors in order that the plan can be enacted. White Doves is a trading style of Grupo MCortexx SL (Spain) and MCortexx Repatriations (Ireland)

Signature:

[group app-2-sign]

Applicant 2

I/We hereby agree to purchase a funeral plan from White Doves Funeral Planning as specified above.
On purchasing my funeral plan, I accept that my personal details will be held for the purpose of administering the plan and will be shared with the relevant individuals and funeral directors in order that the plan can be enacted.
White Doves is a trading style of Grupo MCortexx SL (Spain) and MCortexx Repatriations (Ireland)
Yes

Signature:

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