The Guardian Life Insurance
Company of America
Insurance Company of America
700 South Street COLLATERAL ASSIGNMENT
Pittsfield, MA 01201 Portion of Benefit
Please check the appropriate company(ies). Any insurer checked above is herein referred to as the “Company.”
Berkshire Life Insurance Company of America is a wholly owned stock subsidiary of and an administrator for The Guardian Life Insurance Company of America, New York, NY
For value received, I, (the “Assignor/Owner”), do hereby assign and transfer
a portion of any disability monthly indemnity, not to exceed $ , which may become due or payable under
the Company Policy No. (the “Policy”) to
(“Assignee”) whose address is
Street City State Zip
as collateral security, reserving, however, to myself all other rights under the Policy; and subject, however, to all terms
and conditions of the Policy and to all prior assignments and liens, if any, which may exist on the Policy.
The Assignor/Owner and the Assignee agree that in the event a claim is made under the Policy by reason of the total
disability of the Insured in accordance with the provisions of the Policy, Assignee shall be paid the portion of any disability
monthly indemnity payable as noted above under the Policy. Additionally, the parties agree that if any benefit payable on
this Policy due to a claim is pro-rated for a portion of any given month, the assigned portion will be pro-rated in the same
manner. Residual disability benefits under the Policy are evaluated as a percentage of benefits based on loss of income
during partial disability. The assigned portion will be calculated on the same percentage and paid to Assignee if a claim is
presented and approved for residual disability benefits.
Assignee acknowledges that, in the event of a claim made under the Policy by reason of the disability of the Insured, no
monthly benefit, indemnity, or other payment will be paid unless the Insured shall participate in the claim process as
required by the terms of the Policy, and shall otherwise qualify for benefits, indemnities, or other payments according to
the terms of the Policy. The Company shall not have the obligation to compel or encourage the Insured to so participate,
and Assignee shall hold the Company harmless for any failure or refusal of Insured to so participate. Further, Assignee
acknowledges that participation by Insured is a prerequisite to the issuance of any additional policy of disability insurance
on the life of the insured by way of the exercise of any Future Increase Option or Future Purchase Option that may be part
of the Policy, the Company shall have no obligation to compel or encourage the Insured to participate with the Assignee in
the exercise of any such option, and Assignee shall hold the Company harmless for any failure or refusal of Insured to so
participate. Any additional policies purchased by the Assignor/Owner or Insured are not covered under the terms of this
assignment. To the extent that any other Policy right requires participation by Insured, the Company shall have no
obligation to compel or encourage the Insured to participate with the Assignee, and Assignee shall hold the Company
harmless for any failure or refusal of Insured to so participate. Additionally, Assignee shall hold the Company harmless for
any dispute regarding the Insured's eligibility or coverage under the terms and conditions of the Policy.
The Company shall not be bound or obligated by the terms of any contemporaneous agreement among the parties
The Company is not bound to acknowledge this assignment to successors and assigns of Assignee without written
notification from Assignee of said successor or assign.
No absolute assignments of the Policy by the Assignor/Owner shall be valid without the written consent of the Assignee
Dated at this day of , .
City and State
Witness as to Assignor/Owner’s Signature Assignor/Owner
Dated at this day of , .
City and State
Witness as to Collateral Assignee’s Signature Collateral Assignee (signature of officer, if applicable)
Print Title (if signing on behalf of entity)