Please check one:
p The Guardian Life Insurance Company of America
p The Guardian Insurance & Annuity Co., Inc.
1035 EXCHANGE AGREEMENT
This Agreement is entered into by and between ____________________________________ (hereinafter “Owner”) and the
Company indicated above (hereinafter “Guardian”).
1. Owner is the owner of the following policies or contracts:
Current Policy Number Current Insurer
(collectively hereinafter “Current Policy”).
The Owner represents and warrants that the Current Policy, as listed above: is in force; is unencumbered by any policy
loan; and is not assigned as collateral for a loan. The Owner also represents and warrants that no person, trust, firm,
corporation or any other entity, other than the Owner, has an interest in the policy and that no proceedings of either a
legal or equitable nature have been instituted or are pending against the Owner.
2. a. The Owner of the Current Policy desires to exchange the Current Policy for a new policy issued by Guardian. The
new policy has been applied for by the Owner.
b. Upon the execution of this Agreement, the Owner will either (1) transfer absolute ownership of the Current Policy
to Guardian on forms acceptable to the Current Insurer, simultaneously naming Guardian beneficiary of the
Current Policy; or (2) absolutely assign the Current Policy to Guardian on forms acceptable to the Current Insurer.
Guardian will file the appropriate form, as submitted by the Owner to Guardian, with the Current Insurer at such
time in its underwriting process as Guardian finds it is prepared to offer a new policy to the Owner.
3. Guardian will issue a new policy in accordance with the Owner’s application if all requirements prescribed by Guardian
for this transaction have been met. Guardian shall be free to accept or reject the Owner’s application for the new policy
on the basis of underwriting requirements established and revised from time to time by Guardian. Insurance under the
new policy will be subject entirely to the provisions of the new policy and will not be affected by any provisions of the
Current Policy or this Agreement. Upon Guardian’s rejection of the Owner’s application for a new policy, the Current
Policy shall be returned to the Owner, this Agreement shall become null and void and Guardian will have no further
4. The owner will be responsible for payment of premiums for the Current Policy until such time as the Current Policy has
been surrendered by Guardian in accordance with the terms of this Agreement. If any premium due on the Current
Policy is not paid, Guardian will have the option to treat this Agreement as null and void, and Guardian will be released
from all obligations hereunder and will return the Current Policy to the Owner. Guardian assumes no responsibility for
keeping the Current Policy in force prior to the time it is surrendered to the Current Insurer.
5. The Current Policy will be surrendered by Guardian after it is determined by Guardian that it will issue a new policy to
the Owner. However, no new policy will be issued or delivered to the owner until the Current Policy is surrendered and
all cash surrender funds are received by Guardian. All funds received by Guardian upon surrender of the Current
Policy shall be applied against the new policy as instructed by the Owner in the application for the new policy, all
subject to any limitations set by Guardian.
6. In the event the insured under the Current Policy dies before the new policy is issued and before the Current Policy
has been surrendered, Guardian will pay the net proceeds received, if any, by Guardian from the Current Policy to the
person or persons or entity named as beneficiary of the Current Policy immediately prior to the time when Guardian
became owner and beneficiary or absolute assignee of the Current Policy. Guardian shall then be released from any
and all obligations arising out of this Agreement.
7. If the new policy is not accepted by the Owner during the contractual period specified in the new policy, the Owner
shall have no right to the return of the Current Policy. Upon such failure by the Owner to accept the new policy,
Guardian will pay to the Owner the cash surrender value of the Current Policy received by Guardian. Upon payment of
the cash surrender value to the Owner, Guardian shall be released from any and all obligations arising out of this
8. The Owner agrees to execute any additional forms required by the Current Insurer to make this exchange.
9. a. While the Owner may anticipate that this exchange will result in tax free exchange treatment under Section 1035 of
the Internal Revenue Code of 1986, the Owner understands that this Agreement neither constitutes tax advice
from Guardian nor guarantees tax free treatment under Section 1035 of the Internal Revenue Code of 1986.
b. Guardian is not responsible for the accuracy of any tax information provided by the Current Insurer regarding the
c. Guardian, by virtue of acceptance of this agreement and application for new policy, takes no position on the status
of the new policy as a Modified Endowment Contract under Section 7702A of the Internal Revenue Code of 1986,
10. This agreement shall take effect on the later of the date it is signed by the Owner or filed with Guardian.
Accepted By Guardian: