Irrevocable Assignment Of Death Benefits printable pdf download

IRREVOCABLE ASSIGNMENT OF DEATH BENEFITS

This Irrevocable Assignment is made and entered into this

day of

, 20 ,

by and between

(hereinafter referred to as the “Policyholder”)

and

hereinafter referred to as the “Irrevocable

Assignee”).

RECITALS

The Policyholder wishes to assign and transfer to the Irrevocable Assignee certain rights with respect to a

life insurance policy or annuity contract written by the Catholic Holy Family Society Insurance Company

(Policy #

hereinafter referred to as the “Policy”).

The Policyholder is either receiving public assistance or may want to be eligible to receive public

assistance in the future and wishes to irrevocably waive and assign certain rights the Policyholder has

pursuant to the Policy.

NOW, THEREFORE, in consideration of the above Recitals and of the agreements set forth below, the

policyholder and the Irrevocable Assignee hereby agree as follows:

The Policyholder hereby irrevocably waives any right he or she may have during his or her lifetime to

cancel or revoke this assignment; to receive any refund from the Policy; to surrender the Policy for cash;

or to borrow against the Policy. In waiving these rights, the Policyholder does not assign the rights

waived to any other person and intends that the use of the proceeds from the Policy be used to fund the

cost of funeral goods and services (subject to Paragraph 2 below).

Notwithstanding the waivers set forth above, however, nothing herein shall be construed to deprive the

representatives or family of the Policyholder from procuring and purchasing funeral goods and services

in the open market with the advantages of competition.

IN WITNESS WHEREOF, the Policyholder and the Irrevocable Assignee have executed this

Irrevocable Assignment on the date first above written.

________________________________________

Signature of Policyholder

Date

______________________________________

_______________________________________________

Irrevocable Assignee Signature

Irrevocable Assignee Social Security #/Tax ID #

______________________________________

_______________________________________________

Irrevocable Assignee Address

City, State and Zip Code

_______________________________________________

Irrevocable Assignee Phone #

SPACE FOR HOME OFFICE USE ONLY

RECEIVED AND FILED AT THE HOME OFFICE OF THE CATHOLIC HOLY FAMILY SOCIETY.

______________________________________

_______________________________________________

Date

Secretary

Irrevocable Assignment Of Death Benefits

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