HCC LIFE INSURANCE COMPANY
225 TownPark Drive, Suite 145, Kennesaw, GA 30144 Telephone: (770) 973-9851 Facsimile: (770) 973-9854
AMENDMENT ASSIGNMENT OF GROUP TERM LIFE INSURANCE Policyholder/Employer Name: Employee’s Name and Address: Policy Number: Social Security Number:
As described below, I hereby transfer and assign to my rights, title and interest in and to the above Policy/Certificate of Insurance issued by HCC Life Insurance Company. This assignment is: (check one box only) An Absolute Assignment and Irrevocable by me. A Collateral Security in the amount of $ . If this assignment is an Absolute Assignment of ownership, then the undersigned hereby revokes any prior beneficiary appointment. By reason of the Absolute Assignment, the assignee(s) will possess all the present and future rights and incidents of ownership of the insurance coverage including, but not limited to, the right to change the beneficiary, any right to convert the coverage to an individual policy, and the right to collect all proceeds due under the Policy. If this assignment is made as a Collateral Security, I understand that the right of any beneficiary to proceeds of this insurance will be subordinate to the claim(s) of the Collateral Assignee(s). Any previous beneficiary designation will remain in force for any proceeds remaining after satisfaction of the Collateral Assignee’s claim. I retain the power to designate and/or change the beneficiary and all other rights and duties under the Policy/Certificate. The assignee will not be permitted to pay any contributions becoming due that would be required of me to keep the insurance in force. I understand that neither HCC Life Insurance Company nor the Policyholder assumes responsibility for the sufficiency, validity or effect of this assignment. By executing this assignment, I warrant that no bankruptcy or insolvency proceedings have been instituted by or against me. Signature of Employee: Witness Signature: Assignee(s) Name (Print): Assignee(s) Address: HCC Life Insurance Company acknowledges receipt of this assignment on this date: Signature: Title: Date: Date:
HCC Life Insurance Company Form No. GTL-012-2002
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September, 2005