Insurance Life Assumption Form

INSURANCE LIFE ASSUMPTION FORM

Policy and Parties

Original Policyholder Name:

Policy Number:     Insured Name:

Assumption Applicant (Person Assuming Ownership / Obligations):

Month:    Day:    Year:

Policy Details

Policy Type: Term Whole Universal Other:

Policy Period Effective Date: Month:   Day:   Year:

Policy Period Expiration Date: Month:   Day:   Year:

Coverage and Riders

Applicable Riders and Additional Coverages (select all that apply):
Accidental Death Benefit    Waiver of Premium    Long-Term Care Rider    Viatical/Accelerated Benefit    Other:

Beneficiary Designation

Primary Beneficiary Name:

Relationship:    Percentage: %

Contingent Beneficiary Name:

Relationship:    Percentage: %

Medical, Underwriting and Documentation

Applicant declares whether a current medical examination has been completed in connection with this assumption: Yes No

If completed, Medical Examination Date: Month: Day: Year:

Original Policy or Certified Copy    Completed Assignment/Transfer Form    Medical Reports (if required)
Government-issued ID of Applicant    Beneficiary Consent (if required)    Other:

Exclusions and Limitations

The Assumption is subject to insurer underwriting approval and is subject to the terms, exceptions and exclusions set forth in the policy. Assumption will not take effect and no rights shall vest until (a) the insurer completes any required underwriting and approvals; (b) required premiums and fees are paid; and (c) the insurer receives all required executed assignment documents and consents.

Exclusions include, but are not limited to, contested claims arising prior to the effective date of assumption, misrepresentations in the original application discovered after assumption, and benefits specifically excluded by rider terms. The insurer retains the right to rescind or amend coverage subject to policy provisions and applicable law.

Representations, Authorizations and Certification

By signing below, Applicant affirms the following under penalty of perjury and as a material inducement to the insurer to accept the requested assumption:

1. All information provided in this form is true, complete and accurate to the best of Applicant's knowledge.
2. Applicant authorizes the insurer and its representatives to obtain medical and financial information necessary to evaluate this assumption request and to exchange such information with healthcare providers, medical facilities and reinsurers for underwriting purposes.
3. Applicant understands that insurer approval may require additional documentation, medical examinations or payment of outstanding premiums, and that approval is within the insurer's sole discretion consistent with policy terms.
4. Applicant accepts responsibility for premiums, policy obligations and any future claims arising after the effective date of assumption, subject to the policy terms.
5. Applicant acknowledges potential tax, legal and beneficiary implications of assumption and agrees to seek independent advice regarding such matters if desired.
6. Applicant agrees to indemnify and hold harmless the insurer and Original Policyholder for representations made herein, except as expressly provided by law or policy terms.

Applicant Certification

I hereby apply for assumption of the policy referenced above. I certify that I have the legal capacity to assume ownership and obligations of the policy. I understand that acceptance of this application by the insurer constitutes a binding amendment of ownership and that policy rights, beneficiaries and obligations will be governed by the policy contract as amended by the insurer's approval.

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