Irrevocable Assignment

Page 1

Irrevocable Assignment of Select Ownership Rights Please print all information. Insured

Policy No.

Owner (If other than Insured) Funeral Firm

I, the Owner, hereby transfer selected ownership rights of the policy to the above-named funeral firm. This change is made to comply with state and/or federal public assistance program requirements. I understand that by transferring these ownership rights: 1. This assignment is permanent; and except as stated below, I renounce my power to control the policy; and 2. I waive all rights under the policy to surrender it for cash and to obtain a loan against the policy. 3. I do not assign the rights waived to any other person, including the funeral firm, and the use of the death benefit of the policy is limited to the funding of the cost of the funeral services and merchandise. 4. I understand that it is my personal obligation to pay all premiums due on the policy identified above. Prior to my death, I reserve the right to name a successor funeral firm to provide my funeral. In such an event, I will execute a new assignment in the name of the successor funeral firm which I understand is not binding until received and duly recorded at GBU Financial Life in accordance with the provisions of the contract. Once the successor funeral home assignment is recorded, the above-referenced policy ownership rights and beneficiary designation shall be automatically transferred to the successor funeral home.

Signature of Policy Owner

Date

GBU-IOA 07.17_REV11.21

GBU FINANCIAL LIFE

www.gbu.org service@gbu.org PO Box 645949 Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428


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