SECTION 10.
membership will qualify for a JANAZA financial assistance to their surviving family. Primary Applicant or $1500 Dependent Spouse - $1000 Child
I authorize the following person(s) as recipient(s) of my JANAZA financial assistance. Certain
Documents are required. (Ex. a death certificate and verification of authorized recipient(s), also
other documents may be required.)
Please select a PRIMARY beneficiary and a SECONDARY beneficiary.
Name(s), Address and Phone Number(s) Required.

Anyone can qualify for the JANAZA feature, however, there is a limit of one (1) individual per family
within a 12-month period. This will allow other families to also share in the benefit of this feature.
Ansari Healthsharesm is not responsible for anyone named outside of the person(s) listed to receive
this benefit the names are of the members choosing. Once this qualifying financial benefit has been
distributed Ansari Healthsharesm again is not liable or responsible in any way. If there is a change of
the individuals that you have selected please notify our office with the proper requested documents,
verifying these changes