Assignment of Life Insurance Policy as Collateral

Assignment of Life Insurance Policy as Collateral

LCS09 10/2011

Recorded by Date Page 1 of 1

I. Assignment Information

Policyowner/Assignor Policy Number

Assignee Name Assignee SSN/TIN

Assignee Address Assignee Phone

For value received, the Owner/Assignor hereby assigns the above listed policy to the Assignee, including any supplementary contracts issued under the policy. The assignment is made according to the following terms and is subject to the provisions of the policy and any superior lien of Beneficial Life. The Assignee also agrees to the terms of this assignment.

1. The Assignee may exercise all of the rights, privileges and options of the policy except those reserved to the Assignor in paragraph 2. The Assignee has the sole right to borrow upon the policy, pledge it, surrender it, receive death or endowment proceeds, withdraw advance premiums and exercise all non-forfeiture options of the policy. The Assignee may also exercise any rights and privileges with respect to dividends and divisible surplus, except that until the Assignee notifies Beneficial Life to the contrary. Dividends may be applied by Beneficial Life under the plan in force at the time of this assignment.

2. The Assignor reserves the right to designate and change beneficiaries and elect optional methods of settlement, but the interest of any beneficiary is subject to the rights of the Assignee, including the right to receive payment in one sum, whether this assignment is made before or after the designation of beneficiaries. The Assignor also reserves the right to collect from Beneficial Life any disability benefit payable in cash that does not reduce the amount of insurance.

3. This policy is to be held as security for all liabilities owing the Assignor, by the Assignee, including any which may arise after this assignment.

4. The Assignee agrees not to borrow upon the policy, with the exception of paying premium, or to surrender it until there has been a default in a liability or failure to pay premiums on the policy, nor until 20 days after the assignee has mailed to the Assignor a notice of intent to exercise such right. Any amount in excess of the liabilities secured by this assignment will be paid to the persons entitled to such funds under the policy. Upon request, the Assignee will forward the policy to the insurer in connection with any right which may be exercised by the Assignor or the Assignee.

5. The sole signature of the Assignee will be sufficient for the exercise of any right of Assignee according to this assignment. The insurer need not inquire as to any default in a liability or notice to be given, or as to the application of funds by the Assignee and checks will be drawn to the Assignee alone in such amounts as the Assignee requests under this agreement.

6. The Assignee need not pay any premium, loan, principal, interest, or other charges on the policy, but any such amounts paid by the Assignee will become part of the liabilities secured by the assignment. The amount due will draw interest immediately at a fixed rate not to exceed 6% per annum.

7. The Assignee may take or release other security, may release any party primarily or secondarily liable for any liability, may grant extensions, renewals or indulgences with respect to a liability or may apply funds received under the assignment to the liabilities in such order as the Assignee determines, without regard to other security.

8. If any conflict exists between this assignment and any note or other evidence or liability, this assignment will prevail with respect to the rights under the policy.

9. Each of the undersigned declares that no proceedings in bankruptcy are pending and that the listed property is not subject to any assignment for the benefit of creditors.

II. Authorization

We, the undersigned, hereby authorize the assignment of the listed policy, to the above mentioned Assignee, according to the terms listed.

55 No. 300 West, Suite 375 • Salt Lake City, Utah 84101

(801) 933-1100 • (800) 233-7979 • www.BeneficialFinancialGroup.com

Recorded by Date Page 1 of 1