"ABSOLUTE ASSIGNMENT OF LIFE INSURANCE POLICY See Instructions Below"
First Life America Corporation ABSOLUTE ASSIGNMENT OF LIFE INSURANCE POLICY 1303 SW First American Place Topeka, KS 66604 See Instructions Below: (785) 267-7077 Check Applicable Box (Check only one): ASSIGNMENT BY GIFT: ASSIGNMENT FOR VALUE: As an absolute gift without any consideration whatsoever, For value received and hereby acknowledged, _______________________________________________ (“Owner”) hereby transfers, assigns, and conveys absolutely to _______________________________________________ (“Assignee”), SS No. ________ -- _____ -- __________, all incidents of ownership and control, and all right, title and interest in and to Policy # _________________, including all Supplementary Agreements or Riders attached thereto, but not changing the contractual provisions concerning payment of benefits, issued by FIRST LIFE AMERICA CORPORATION, on the life of ___________________________ (“Insured”) in the principal or face amount of $_____________ in which ______________________ (“Current Beneficiary”) is designated as beneficiary, with the right of revocation reserved. It is understood by the undersigned’s that if the subject policy was issued when the insured was a juvenile, this assignment may be subject to policy provisions, if any, which designate the insured as owner upon the attainment of a specified age. It is requested by the undersigned’s that the beneficiary of this policy, upon execution of this assignment, shall be: _________________________________________________ __________ ________________________________ Primary Beneficiary Age Relationship _________________________________________________________________________________________________ Address _________________________________________________ __________ ________________________________ Contingent Beneficiary Age Relationship _________________________________________________________________________________________________ Address _____________________________ (“Assignee”) hereby authorizes and directs the Company to deal with him/her as absolute assignee of said policy at the following address: ____________________________________________________ __________________________________________________________________________________________________ IN WITNESS THEREOF, Owner and Assignee have set their hands this ________ day of ____________, 20______ ___________________________________________ ___________________________________________ Witness Owner ___________________________________________ ___________________________________________ Witness Assignee Company Endorsement: Recording Date:__________________ Initials: ___________ Approved By: ____________________________________ Notice: An Assignment of the policy may create tax consequences. The current owner should seek professional tax advice if there are any questions. The Company assumes no responsibility for the validity or sufficiency of any assignment and the assignment is not valid until endorsed by the Company. INSTRUCTIONS FOR ABSOLUTE ASSIGNMENT: 1. Use black or blue ink only. Do not use a pencil. 2. Indicate type of assignment (either Gift or for Value). 3. Indicate name of present owner in blank followed by (“Owner”). 4. Indicate name of NEW owner in blank followed by (“Assignee”). 5. Indicate the insured’s name in the blank followed by (“Insured”) 6. Indicate face amount of policy in the next blank following the $ sign. 7. Indicate CURRENT beneficiary in blank followed by (“Current Beneficiary”). 8. Indicate name of beneficiary, their relationship and age following assignment. Complete this even though beneficiary may not change. 9. Indicate address of new assignee 10. State Assignee’s Social Security Number. 11. Date and sign the form, include title of person signing for a company and witness signatures of present owner and new assignee. POS-202 (5/02)