| BE IT KNOWN, for value received, the undersigned
of hereby irrevocably transfers and assigns to all legal and beneficial right,
title and interest in and to the within policy of insurance standing in
my name and known as Policy No. issued by the Insurance Company.
I also assign all cash values, proceeds and benefits thereto arising,
subject to the conditions of said policy and the requirement of the issuing underwriter:
The undersigned warrants that it has full authority to transfer said policy, and shall execute all further documents as may be required,
by the underwriter.
This assignment shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal representatives.
Signed this day of , 20 .
In the presence of:
_______________________________ ____________________________
Witness Name
____________________________
Address
____________________________
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