Online Membership Application

Member Information
Name*
Prefix First Last Suffix
DOB*
Date Format: MM slash DD slash YYYY
SSN*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
Secondary Phone Number
Email*
Enter Email Confirm Email
Primary Beneficiary Information
Primary Beneficiary Name*
First Last
Relationship to Member*
Primary Beneficiary Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Beneficiary Phone*
Secondary Beneficiary Information
Secondary Beneficiary Name
First Last
Relationship to Member
Secondary Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Beneficiary Phone
Payment Information
AEEEA, Inc. Registration Fee*
Price: $125.00
Total
$0.00
Membership Notice
As a member, your beneficiary will receive:
- $20,000 minus the cost of funeral services after One Hundred Eighty (180) days of membership, or we have 750 enrolled members, which ever shall first occur. One Hundred Eighty (180) days of membership is the grace period required for a member's beneficiary to be entitled to collect the outlined benefits.
As a member, you will:
- Agree to pay $125.00 ($100.00 for the membership fee and $25.00 for the registration fee. Benefits to be paid are for the member only.
- Be required to pay $35.00 for ever member's death. Payments must be made within seven (7) days after receiving notice of a member's death.
As a member, I understand and agree that:
- Should I fail or refuse to pay the required amount for every member's death, my membership will be revoked and I will not be entitled to receive any type of refund for what I have already paid.
- As a member of AEEEA, I acknowledge that all information provided is true and correct. If there is a change in any information provided, it is my responsibility to contract AEEEA. All communications sent to me will be at the email address I have provided and at my primary telephone number.
- I understand and agree that the required amount to be paid for every member’s death is subject to change based upon funeral services and cemetery costs.
- I understand and agree that there is an annual renewal fee for membership is currently $10.00 and is subject to change based upon administrative fees.
Signature*
Date Signed*
Date Format: MM slash DD slash YYYY
Total
$0.00

ONLINE MEMBERSHIP APPLICATION

Member Information

Primary Beneficiary Information

Secondary Beneficiary Information

Payment Information

Membership Notice