Assignment To Funeral Home Form – Fill Out and Use This PDF

ASSIGNMENT OF POLICY/CONTRACT DEATH BENEFITS

For value to be received and services to be performed by __________________________ of

_______________________, (“Funeral Home”), I hereby assign, transfer and set over to the Funeral Home the sole

right to collect from ________________________ (“Insurance Company”) the net proceeds of Policy/Contract

Number _______________, when it becomes a claim by death of the insured. It is expressly understood that the

Company is hereby authorized and directed to release and pay the net death benefits payable, as determined by the provisions of the above stated Policy/Contract, to the Funeral Home upon receipt of a properly certified Death Certificate, surrender of the above stated Policy/Contract and satisfactory proof of claim as deemed necessary by the Company.

_____ IRREVOCABLE ASSIGNMENT (Must be checked if selecting Irrevocable Assignment.)

It is expressly understood that:

1The Owner hereunder having so requested, it is agreed and understood that the Owner may not revoke the Assignment of Policy/Contract Death Benefits. While said Policy/Contract remains payable to the Funeral Home, the Owner, may not make loans on the cash value or exercise any other option, right or privilege provided in the Policy/Contract including, but not limited to, the right to elect any of the nonforfeiture provisions thereof. Paid-Up Additions must be kept intact. While the Owner may elect to make the Policy/Contract irrevocable, the Owner may always transfer the proceeds of the Policy/Contract to another Funeral Home permit holder to provide the services specified in the Policy/Contract.

2This Assignment of Policy/Contract Death Benefits shall not become effective until 30 days after the effective date of the Policy/Contract.

_____ REVOCABLE ASSIGNMENT (Must be checked if selecting Revocable Assignment.)

It is expressly understood that:

1The named Owner of the Policy/Contract may cancel and revoke this Assignment of Policy/Contract Death Benefits at any time prior to the death of the Insured, by filing proper written notice of cancellation with the Company at the above address. If the Assignment is canceled, the net death benefits referred to herein are to be paid to the Beneficiary named in the Policy/Contract in accordance with the Policy/Contract provisions unless a subsequent Assignee is designated.

2The ownership rights of the Policy/Contract are reserved to the named Owner and are excluded from this Assignment and do not pass by virtue hereof.

3In the event that this Assignment of Policy/Contract Death Benefits is canceled by the Policy/Contract Owner prior to the death of the Insured or in the event cash values are withdrawn or surrendered, the Prepaid Funeral Benefits Contract executed by and between the Funeral Home and the Purchaser shall, by virtue of its provisions, become null and void. In such event, at the death of the Insured all death benefits shall be payable to the named Beneficiary in accordance with the provisions of the Policy/Contract.

IN WITNESS WHEREOF, this Assignment of Policy/Contract Death Benefits is signed on this ____ day of

_____________________, 20___ at __________________________, ________________.

_______________________________	__________________________________
Witness	Policy/Contract Owner

AS-2 (10/11)