Fill and Sign the Assignment of Life Insurance as Collateral Form

- 1 -ASSIGNMENT OF LIFE INSURANCE POLICY AS COLLATERAL A . FOR VALUE RECEIVED the undersigned,       , hereby assigns, transfers and sets over to       ,       ,       , its successors and assigns, (herein called the "Assignee") Policy No.       issued by the       (herein called the "Insurer") and any supplementary contracts issued in connection therewith (said policy and contracts being herein called the "Policy"), upon the life of       whose address is       and all claims, options, privileges, rights, title and interest therein and there under (except as provided in Paragraph C hereof), subject to all the terms and conditions of the Policy and to all superior liens, if any, which the Insurer may have against the Policy. The undersigned by this instrument jointly and severally agree and the Assignee by the acceptance of this Assignment agrees to the conditions and provisions herein set forth. B . It is expressly agreed that, without detracting from the generality of the foregoing, the following specific rights are included in this Assignment and pass by virtue hereof: 1 . The sole right to collect from the Insurer the net proceeds of the Policy when it becomes a claim by death or maturity; 2 . The sole right to surrender the Policy and receive the surrender value thereof at any time provided by the terms of the Policy and at such other times as the Insurer may allow; 3 . The sole right to obtain one or more loans or advances on the Policy, either from the Insurer or, at any time, from other persons, and to pledge or assign the Policy as security for such loans or advances; 4 . The sole right to collect and receive all distributions or shares of surplus, dividend deposits or additions to the Policy now or hereafter made or apportioned thereto, and to exercise any and all options contained in the Policy with respect thereto; provided, that unless and until the Assignee shall notify the Insurer in writing to the contrary, the distributions or shares of surplus, dividend deposits and additions shall continue on the plan in force at the time of this Assignment; and 5 . The sole right to exercise all no forfeiture rights permitted by the terms of the Policy or allowed by the Insurer and to receive all benefits and advantages derived there from. - 2 -C . It is expressly agreed that the following specific rights, so long as the Policy has not been surrendered, are reserved and excluded from this Assignment and do not pass by virtue hereof: 1 . The right to collect from the Insurer any disability benefit payable in cash that does not reduce the amount of insurance; 2 . The right to designate and change the beneficiary; 3 . The right to elect any optional mode of settlement permitted by the Policy or allowed by the Insurer; but the reservation of these rights shall in no way impair the right of the Assignee to surrender the Policy completely with all its incidents or impair any other right of the Assignee hereunder, and any designation or change of beneficiary or election of a mode of settlement shall be made subject to this Assignment and to the rights of the Assignee hereunder. D . This Assignment is made and the Policy is to be held as collateral security for any and all amounts owing under promissory note(s) or other loan documents, and any extension or renewal thereof, (herein called "Liability") of the undersigned, or any of them, to the Assignee when such promissory note(s) or other loan documents contain a provision that they are secured by the Policy assigned under this Assignment. E . The Assignee covenants and agrees with the undersigned as follows: 1 . That any balance of sums received hereunder from the Insurer remaining after payment of the Liability shall be paid by the Assignee to the persons entitled thereto under the terms of the Policy had this Assignment not been executed; and 2 . That the Assignee will upon request forward without unreasonable delay to the Insurer the Policy for endorsement of any designation or change of beneficiary or any election of an optional mode of settlement. F . The Insurer is hereby authorized to recognize the Assignee's claims to rights hereunder without investigating the reason for any action taken by the Assignee, or the validity or the amount of the Liability or the existence of any default therein, or the giving of any notice under Paragraph E (2) above or otherwise, or the application to be made by the Assignee of any amounts to be paid to the Assignee. The sole signature of the Assignee shall be sufficient for the exercise of any rights under the Policy assigned hereby and the sole receipt of the Assignee for any sums received shall be a full discharge and release therefore to the Insurer. Checks for all or any part of the sums payable under the Policy and assigned herein, shall be drawn to the exclusive order of the Assignee if, when, and in such amounts as may be, requested by the Assignee. G . The Assignee shall be under no obligation to pay any premium, or the principal of or interest on any loans or advances on the Policy whether or not obtained by the Assignee, or any other charges on the Policy, but any such amounts so paid by the Assignee from its own funds, shall become a part of the Liability hereby secured, shall be due immediately, and shall bear interest at the maximum rate permitted by law. - 3 -H . The exercise of any right, option, privilege or power given herein to the Assignee shall be at the option of the Assignee, but (except as restricted by Paragraph E (2) above) the Assignee may exercise any such right, option, privilege or power without notice to, or assent by, or affecting the liability of, or releasing any interest hereby assigned by the undersigned, or any of them. I . The Assignee may take or release other security, may release any party primarily or secondarily liable for the Liability, may grant extensions, renewals or indulgences with respect to the Liability, or may apply to the Liability in such order as the Assignee shall determine, the proceeds of the Policy hereby assigned or any amount received on account of the Policy by the exercise of any right permitted under this Assignment, without resorting or regard to other security. J . In the event of any conflict between the provisions of this Assignment and provisions of the note or other evidence of the Liability, with respect to the Policy or rights of collateral security therein, the provisions of this Assignment shall prevail. K . Each of the undersigned declares that no proceedings in bankruptcy are pending against him and that his property is not subject to any assignment for the benefit of creditors. Signed this day of , ______ . ________________________________ Insured or Owner ________________________________ Address ________________________________ Beneficiary _______________________________ Address - 4 -STATE OF _________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said County and State, on this day of , _______ , within my jurisdiction, the within named ____________ , who acknowledged that [he] - 5 -[she] [they] executed the above and foregoing instrument. _____________________________ NOTARY PUBLIC My Commission Expires: - 6 -STATE OF _______________ COUNTY OF _____________ - 7 -Personally appeared before me, the undersigned authority in and for the said County and State, on this day of , _____ , within my jurisdiction, the within named _____________ , who acknowledged that [he] [she] is ____________ of ______________ , a _________ corporation, and that for and on behalf of the said corporation, and as its act and deed, [he] [she] executed the above and foregoing instrument, after first having been duly authorized by said corporation so to do. _____________________________ - 8 -NOTARY PUBLIC My Commission Expires: INSURER'S ACKNOWLEDGMENT OF RECEIPT Receipt of the Assignment of Life Insurance Policy as Collateral is hereby acknowledged. THIS, the day of , ____. _____________________ INSURER _____________________ By TITLE: ______________