A statement of funeral goods and services selected for the deceased is attached hereto. Beneficiary. (Signature). Applications must be submitted within 14 days of the date of death; the county will not reimburse payments already made.See immediate burial policy. Below is a list of frequently requested Human services forms. Click on the form to complete and print. How to fill out the Insurance Proceeds Assignment Form for Funeral Services? 1. Enter the insurance company name and policy number. 2.