Insurance Assignment Form

INSURANCE ASSIGNMENT FORM

This Insurance Assignment Form (the Assignment) documents the transfer of rights in insurance benefits, proceeds, and related claims from the Assignor to the Assignee under the terms set forth below.

Assignor (Policyholder)

Assignor Name:

Date of Birth:    Policy Number:

Assignee (Recipient)

Assignee Name:

Assignee Contact Name:    Assignee Tax/ID Number:

Policy Details

Insurer Name:

Property     Liability     Automobile     Medical Payments     Life     Disability     Other:

Coverage Limit / Policy Limit:    Deductible:    Premium:

Policy Period Start:    Policy Period End:

Assignment Details

Effective Date of Assignment:

This Assignment transfers and assigns to the Assignee all rights, title, interest, and proceeds payable under the referenced policy with respect to claims described herein, including but not limited to payment of loss, claim proceeds, recoveries, and any reimbursement related to the assigned claim(s) to the extent of Assignee's interest. Assignor represents and warrants that Assignor is the named insured or has the authority to assign such rights.

Assigned Claim(s) (if applicable)

Date of Loss:    Insurer Claim Number:

Exclusions and Limitations

Unless expressly set forth herein, this Assignment does not expand, alter, or create coverage under the policy, and does not relieve Assignor of any policy obligations. Assignee acknowledges that assigned rights are subject to the terms, conditions, exclusions, and defenses of the policy.

Beneficiary Information (if assignment affects beneficiary status)

Beneficiary Name:

Relationship to Assignor:    Allocation Percentage: %

Representations, Warranties and Indemnity

Assignor represents and warrants that: (a) Assignor is the lawful owner of the rights being assigned; (b) there are no prior assignments or encumbrances affecting the assigned rights except as disclosed herein; (c) to Assignor's knowledge, no material misstatement or omission has been made to the insurer with respect to the assigned claim(s); and (d) Assignor has full authority to execute this Assignment. Assignor shall indemnify and hold Assignee harmless from and against any claims, demands, liabilities, or expenses arising from any breach of these representations and warranties.

Notice and Delivery

Notices required under this Assignment shall be in writing and delivered to the addresses set forth above by hand, certified mail, or nationally recognized overnight courier and shall be effective upon receipt.

Miscellaneous

Governing Law: This Assignment shall be governed by and construed in accordance with the laws of the state governing the policy unless otherwise agreed in writing. Any disputes arising out of this Assignment shall be subject to the exclusive jurisdiction of the courts of that state.

Severability: If any provision of this Assignment is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Entire Agreement: This Assignment constitutes the entire agreement between the parties with respect to the subject matter contained herein and supersedes all prior agreements and understandings, whether written or oral, concerning such subject matter.

Acknowledgment and Certification

By signing below, Assignor certifies under penalty of perjury that the statements contained in this Assignment are true and correct to the best of Assignor's knowledge, that Assignor has the authority to assign the rights described herein, and that Assignor authorizes the insurer to pay assigned proceeds directly to Assignee to the extent provided in this Assignment.

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