ReliaStar Life Insurance Company
P.O. Box 20, Minneapolis, Minnesota 55440
ABSOLUTE ASSIGNMENT OF INDIVIDUAL LIFE INSURANCE
Not valid unless signed by ReliaStar Life Insurance Company Registrar in Minneapolis
IMPORTANT INSTRUCTIONS: This form must be completed, signed, and dated. Send forms to ReliaStar Life’s Home
Office in Minneapolis for Registrar’s signature. If the Policy is administered by other than ReliaStar Life, the Administrator
must also send copies of the Insured’s application and any beneficiary changes and previous assignments. Assignments will
only be accepted as provided in the Policy. This is not a Collateral Assignment. The Insured should check with a legal or tax
advisor before making an Assignment. A wife’s given name must be used (i.e. “Jane Doe” not “Mrs. John Doe”).
If the Assignee predeceases the Insured, please contact ReliaStar Life for instructions.
Policy Number Sponsoring Group Name, if any
Name of Insured Name of Assignee
Complete Address of Insured Complete Address of Assignee
I hereby assign and transfer, for value received, the sufficiency of which is hereby acknowledged and/or for love and affection
and no other valuable consideration, to the above named assignee, absolutely and forever, all incidents of ownership of the
insurance on the life of the Insured provided under the captioned life insurance Policy and any riders attached thereto,
together with all rights, claims, and advantages whatsoever, now due or hereafter to arise or to be had or made by virtue
The right of conversion option, if any, and the right to change the beneficiary are two of the rights so assigned and
transferred, BUT IT IS NOT INTENDED HEREBY TO CHANGE OR REVOKE THE BENEFICIARY NOW IN EFFECT.
Note: In some states, if a viatical settlement is involved in the transfer of ownership, then the ownership of accidental death
benefits under the Policy, if any, is not transferable to the viatical settlement provider nor may the viatical settlement provider
be the beneficiary for accidental death benefits.
This assignment includes all insurance now in effect, or that may become effective in the future, under the captioned life
insurance Policy. It is understood and agreed that this assignment is made subject to any indebtedness to, or lien in favor of,
Dated at this day of , 20 .
Signature of Insured or Present Owner Witness
Signature of Assignee Witness
NOTE: This assignment cannot be released – a new assignment can be made by the current Assignee. Once an
assignment has been made, only the Assignee can make beneficiary changes, assignment, or application for conversion.
ReliaStar Life assumes no responsibility as to the effect, sufficiency or validity of the above assignment.
Received and filed at the Home Office of ReliaStar Life Insurance Company at Minneapolis, Minnesota on:
By Company Registrar .
ReliaStar Life will return the signed form to the Administrator if other than ReliaStar Life. The Administrator must then give
the original form to the Assignee and keep a copy of the Assignment in their file. In the event of a claim, a copy of the
Assignment must be submitted with the claim.
E-Ship: 125691 (01/03)