Assignment of Insurance Policy as Collateral
INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY
ADMIN 5519 (01-2011) Fidelity & Guaranty Life Insurance Company Des Moines, IA
A. For Value Received the undersigned hereby assign, transfer and set over to of
(Address) (City, State, Zip Code)
Loan No. _____________________, its successors and assigns (herein called the “Assignee”), Policy No.
_______________________ issued by Fidelity and Guaranty Life Insurance Company or Americom Life and Annuity (herein
called the “Insurer”), and any supplementary contracts issued in connection therewith (said policy and contracts being herein
called the “Policy”), upon the life of ______________________________ of _______________________________ and all claims,
options, privileges, rights, title and interest therein and there under (except as provided in Paragraph C hereof), subject to all the
terms and conditions of the Policy and to all superior liens, if any, which the Insurer may have against the Policy. The
undersigned by this instrument jointly and severally agree and the Assignee by the acceptance of this assignment agrees to the
conditions and provisions herein set forth.
B. It is expressly agreed that, without detracting from the generality of the foregoing, the following specific rights are included in this
assignment and pass by virtue hereof:
1. The sole right to collect from the Insurer the net proceeds of the Policy when it becomes a claim by death or maturity;
2. The sole right to surrender the Policy and receive the surrender value thereof at any time provided by the terms of the Policy
and at such other times as the Insurer may allow;
3. The sole right to obtain one or more loans or advances on the Policy, either from the Insurer or, at any time, from other
persons, and to pledge or assign the Policy as security for such loans or advances;
4. The sole right to collect and receive all distributions or shares of surplus, dividend deposits or additions to the Policy now or
hereafter made or apportioned thereto, and to exercise any and all options contained in the Policy with respect thereto;
provided, that unless and until the Assignee shall notify the Insurer in writing to the contrary, the distributions or shares of
surplus, dividend deposits and additions shall continue on the plan in force at the time of this assignment; and
5. The sole right to exercise all non-forfeiture rights permitted by the terms of the Policy or allowed by the Insurer and to receive
all benefits and advantages derived there from.
C. It is expressly agreed that the following specific rights, so long as the Policy has not been surrendered, are reserved and excluded
from this assignment and do not pass by virtue hereof:
1. The right to collect from the Insurer any disability benefit payable in cash that does not reduce the amount of insurance;
2. The right to designate and change the beneficiary;
3. The right to elect any optional mode of settlement permitted by the Policy or allowed by the Insurer;
but the reservation of these rights shall in no way impair the right of the Assignee to surrender the Policy completely with all its
incidents or impair any other of the Assignee hereunder, and any designation or change of beneficiary or election of a mode of
settlement shall be made subject to this assignment and to the rights of the Assignee hereunder.
D. This assignment is made and the Policy is to be held as collateral security for any and all liabilities of the undersigned, o r any of
them, to the Assignee, either now existing or that may hereafter arise in the ordinary course of business between any of the
undersigned and the Assignee (all of which liabilities secured or to become secured are herein called “Liabilities”).
E. The Assignee covenants and agrees with the undersigned as follows:
1. That any balance of sums received hereunder from the Insurer remaining after payment of the then existing Liabilities,
matured or unmatured, shall be paid by the Assignee to the persons entitled thereto under the terms of the Policy had this
assignment not been executed;
2. That the Assigns will not execute either the right to surrender the Policy or (except for the purpose of paying premiums) the
right to obtain policy loans from the Insurer, until there has been default in any of the Liabilities or a failure to pay any
premium when due, nor until twenty days after the Assignee shall have mailed, by first-class mail, to the undersigned at the
address last supplied in writing to the Assignee specifically referring to this assignment, notice of intention to exercise such
right: and
3. That the Assignee will upon request forward without unreasonable delay to the Insurer the Policy for endorsement of any
designation or change of beneficiary or any election of an optional mode of settlement.
F. The Insurer is hereby authorized to recognize the Assignees’ claims to rights hereunder without investigating the reason for any
action taken by the Assignee, or the validity or the amount of the Liabilities or the existence of any default therein, or the giving of
any notice under Paragraph E(2) above or otherwise, or the application to be made by the Assignee of any amounts to be paid to
the Assignee. The sole signature of the Assignee shall be sufficient for the exercise of any rights under the Policy assigned
hereby and the sole receipt of the Assignee for any sums received shall be a full discharge and release therefore to the Insurer.
Checks for all or any part of the sums payable under the Policy and assigned herein, shall be drawn to the exclusive order of the
Assignee if, when, and in such amounts as may be, requested by the Assignee.
Complete form in triplicate and forward to the Insurer
