Employee Owned Life Insurance Form

Employee Owned Life Insurance Form

Recitals

WHEREAS Employer Name: (hereinafter "Employer") employs Employee Name: (hereinafter "Employee");

WHEREAS the parties intend that a life insurance policy be issued on the life of Employee, with initial carrier Insurance Carrier: and policy number Policy No.: , and that the Employer shall be the initial owner of the policy subject to the terms set forth herein.

WHEREAS Employee acknowledges receipt of written notice regarding ownership, assignment, and possible tax consequences and hereby consents to Employer ownership and the administration terms set forth in this Agreement.

Scope of Services

Policy Details & Beneficiary

Payment Terms

Premium Amount: payable according to the schedule described below. Premiums may be paid by Employer direct payment, payroll deduction, or a combination as authorized by Employee.

Employee authorizes payroll deduction for premiums: Check to authorize

Late payment shall incur a fee equal to of the overdue premium for each payment period following a grace period of days. Repeated non-payment may result in policy lapse in accordance with carrier provisions.

Term and Termination

This Agreement commences on Start Date: and continues until End Date: unless earlier terminated under the terms below.

Either party may terminate this Agreement for any material breach by providing written notice and allowing the other party the termination notice period specified above to cure such breach. Termination will not relieve Employee or Employer of obligations accrued prior to the effective date of termination, including premium payment and reimbursement obligations.

Ownership, Assignment & Employee Consent

Employer shall be the initial owner and beneficiary of the policy unless otherwise stated in writing. Employee acknowledges that Employer's ownership may result in Employer receiving proceeds while Employee is employed by Employer unless otherwise designated.

Employee consents to Employer ownership and to any assignment recorded with the insurer required to effectuate Employer ownership: Consent to Ownership: Check to consent

Confidentiality

All non-public information concerning the policy, premium amounts, beneficiary designations, and medical or underwriting information obtained by Employer under this Agreement shall be treated as Confidential Information. Employer shall restrict access to Confidential Information to personnel with a legitimate need to know and shall not disclose such information except as required by law or with Employee's written consent.

Tax and Legal Acknowledgment

Employee acknowledges that Employer ownership of a life insurance policy on the Employee may have tax consequences, including potential gift or income tax implications. Employee affirms that Employee has had the opportunity to obtain independent tax or legal advice and that Employee's signature below is a voluntary informed consent.

Employee acknowledges receipt of a copy of this Agreement: Employee Received Copy: Check to acknowledge

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles.

Entire Agreement

This Agreement, including any attached exhibits, constitutes the entire agreement between Employer and Employee with respect to the subject matter hereof and supersedes all prior negotiations, understandings, and agreements. Any amendment must be in writing and signed by both parties.

Additional Provisions

Acknowledgement of Receipt

By signing below, the parties acknowledge that they have read and understand this Agreement, that the information provided herein is true and correct to the best of their knowledge, and that they agree to be bound by its terms.

Sign Now