Fill and Sign the Funeral Home Assignment Form

Assignment of Life Insurance Proceeds to a Funeral Home for the Purpose of Pre-Arranging a Funeral Assignment made __________________ (date of assignment) , by ________________________ (Name of Assignor) , of ________________________________ _______________________________________ (Address of Assignor) , hereinafter called the Assignor, to ___________________________ (Name of Funeral Home) , a corporation organized and existing under the laws of the state of ______________, with its principal office located at ____________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as the Funeral Home . For and in consideration of the promise of the Funeral Home to provide specified goods and services under this Agreement for the benefit of ______________________ (Name of Person who will receive funeral upon death) , Assignor irrevocably assigns all incidents of ownership of the Policy to the Funeral Home pursuant to this Agreement. Assignor acknowledges that this assignment is permanent and cannot be revoked. Assignor waives all rights under the Policy to change the beneficiary, obtain a loan against the Policy, surrender the Policy for cash, and change the owner of the Policy. Assignor has no intent to void the Policy and receive a refund. By signing this Agreement, Funeral Home agrees to immediately transfer its ownership rights under the assignment to the ________________________ (name of trust) , which will hold the Policy, in trust for the benefit of _________________________ (Name of Person who will receive funeral upon death) . Funeral Home and the Assignor of the Policy agree that after the death of ____________________________ (Name of Person who will receive funeral upon death) , the Trustee will pay the Policy proceeds to the Funeral Home, if it still provides funeral services and burial, or to another funeral home if, for some reason, another funeral home provides the funeral services and burial. WITNESS our signatures as of the day and date first above stated. ____________________________ (Name of Funeral Home) By:______________________________ ________________________ (Printed name & Office in Corporation) (Printed Name of Assignor) ___________________________ ________________________ ___________________________ (Signature of Assignor) (Signature of Officer)