Fill and Sign the Collateral Assignment of Life Insurance Policy Form

Partial Assignment of Life Insurance Policy as Collateral No assignment of a policy, or of any interest therein, will be binding on the Company unless such assignment, or a signed or certified copy thereof, is filed at the Administrative Office of __________, __________, __________, __________. __________ assumes no respon sibility as to the validity of any assignment. A. For Value Received the undersigned hereby assigns, transfers and sets over to __________ of __________, __________, its successors and assigns (herein called the "Assignee") a portion of the proceeds payable under Policy No._______________ issued by __________ (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 __________ of __________, __________ and all claims options, privileges, rights, title and interest attributable to said partial assignment (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 assign ment 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 partial assignment and pass to Assignee by virtue hereof: 1. The sole right to collect from the Insurer the first _____________ Dollars ($00.00) of net proceeds from the Policy when it becomes a claim by death or maturity; 2. In the event of a default by the undersigned under that certain Loan Agreement and related documents dated __________, _______ (hereinafter collectively "Loan Agreement") with Assignee, Assignee shall have the sole right to surrender the Policy and receive the first ______________ Dollars ($00.00) of surrender value thereof; 3. In the event of a default by the undersigned under the Loan Agreement with Assignee, Assignee shall have the sole right to obtain one or more loans or advances on the first ____________ Dollars ($00.00) of value of the Policy, either from the Insurer or, from other persons, and to pledge or assign the Policy as security for such loans or advances; 4. In the event of a default by the undersigned under the Loan Agreement with Assignee and written notice to Insurer, Assignee shall have the sole right to collect and receive the first ____________ Dollars ($00.00) of all distributions or shares of surplus, dividend deposits or additions to the Policy now or hereafter made or appor tioned 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 nonforfeiture rights permitted by the terms of the Policy or allowed by the Insurer and to receive all benefits and advan tages derived therefrom. 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 rights 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 this rights of the Assignee hereunder. D. This partial assignment is made and the Policy, to the extent of the first _________ Dollars ($00.00) of value in said Policy, and is to be held, to the extent specified, as collateral security for all liabilities of the undersigned to the Assignee arising out of the Loan Agreement (all of which liabilities secured or to become secured are herein called "Liabilities"). 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 then existing Liabilities, matured or unmatured, shall be paid by the Assignee to the persons entitled thereto under the terms of the Policy as if this assignment had not been executed; 2. That the Assignee will not exercise either the right to surrender the Policy (except for the purpose of paying premiums) the right to obtain policy loans from the Insurer, until there has been default in any of the Liabilities or a failure to pay any premium when due, nor until twenty days after the Assignee shall have mailed, by first class mail, to the undersigned at the addresses last supplied in writing by the undersigned, notice of intention to exercise such right; and 3. 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 its rights hereunder without investigating the reason for any action taken by the Assignee, or the validity or the amount of the Liabilities 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 interest and right assigned hereby and the sole receipt of the Assignee for any sums received shall be a full discharge and release therefor to the Insurer. Any checks for the portion of the sums payable under the Policy which are 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 apart of the Liabilities hereby secured, shall be due immediately., and shall draw interest at a rate fixed by the Assignee from time to time not exceeding 6% per annum. 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 herein) 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. I. The Assignee may take or release other security, may release any party primarily or secondarily liable for any of the Liabilities, may grant extensions, renewals or indulgences with respect to the Liabilities, or may apply to the Liabilities in such order as the Assignee shall determine, the first ________ Dollars ($00.00) of proceeds of the Policy as 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 Loan Agreement, with respect to the Policy or rights of collateral security therein, the provisions of this assignment shall prevail. K. 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. L. If any provision or provisions of this assignment are invalid, for any reason whatsoever, such invalidity shall in no way impair or affect the validity of other provisions. Signed At __________, __________, this the __________ day of __________, _________. __________________________ Signature of Present Owner __________________________ Signature of any prior Assignee __________________________ Signature of Irrevocable Beneficiary This is to certify that a copy of this form has been recorded by the Company on __________. by _______________________ Registrar for the Company ACKNOWLEDGMENT State of __________ } SS: County OF __________ On this day of __________, _______, before me personally came __________ to me known to be the person described in and who executed the foregoing instrument and acknowledged to me that he executed the same. My commission expires: ______________ ____________ NOTARY PUBLIC RELEASE OF ASSIGNMENT FOR VALUE RECEIVED, all the right, title and interest heretofore transferred to the undersigned by the within instrument is hereby relinquished and released. Dated __ A COPY OF THIS RELEASE OF ASSIGNMENT HAS BEEN PLACED ON FILE __________________ REGISTRAR NOTE: If executed by a Corporation the Corporate Seal must be affixed.