IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY
FOR VALUE RECEIVED, I(WE), THE UNDERSIGNED BENEFICIARY(IES) UNDER THE INSURANCE POLICY(IES), OR DEATH BENEFIT
CERTIFICATE(S) (COLLECTIVELY, THE “POLICY(IES)”) REFERRED TO BELOW, OR BEING THE PERSON EQUITABLY ENTITLED TO THE
BENEFITS THEREUNDER ISSUED BY____________________________________________________________ (NAME OF INSURANCE COMPANY)
POLICY NUMBER(S):
ON THE LIFE OF
_______________________
(POLICY NUMBER)
________________________
(POLICY NUMBER)
_______________________
(POLICY NUMBER)
_______________________
(POLICY NUMBER)
___________________________________________________ (THE “DECEASED”) DO HEREBY IRREVOCABLY ASSIGN, SET
OVER AND TRANSFER UNTO
ASSIGNS, THE SUM OF
________________________________________________ (THE “FUNERAL HOME”) ITS SUCCESSORS AND
____________________________________________________________________________ ($____________________)
(WRITE IN THE AMOUNT BEING APPLIED IN DOLLARS AND CENTS)
(DOLLARS)
TO BE PAID FROM THE BENEFITS OF THE ABOVE-MENTIONED POLICY(IES), PLUS STATUTORY INTEREST FROM THE DECEASED’S DATE OF DEATH, THE
CONSIDERATION FOR THE ASSIGNMENT OF THIS AMOUNT BEING (1) FUNERAL SERVICES RENDERED IN THE BURIAL OF SAID DECEASED BY THE
FUNERAL HOME, WHICH SERVICES HAVE BEEN ACCEPTED BY US AND/OR (2) FUTURE PROVISION OF THE ABOVE-MENTIONED SERVICES. IN THE
EVENT THAT THE INSURANCE COMPANY SETTLEMENT AMOUNT ON THE POLICY(IES) IS LESS THAN THE AMOUNT OF THIS ASSIGNMENT, I(WE) AGREE
TO PAY THE DEFICIT TO THE FUNERAL HOME AND/OR ITS ASSIGNEE UPON REQUEST TO PAY. IF ANY PAYMENTS OF THE SAID PROCEEDS ARE
ERRONEOUSLY MADE TO ME (US) UNDER THE PROVISIONS OF THE ABOVE DESCRIBED POLICY(IES), SUBSEQUENT TO THE EXECUTION OF THIS
ASSIGNMENT, THEN I(WE) AGREE TO HOLD THE SAID PROCEEDS IN TRUST FOR THE USE OF THE FUNERAL HOME AND ITS ASSIGNEE, THEIR
SUCCESSORS AND ASSIGNS.
THE UNDERSIGNED HEREBY APPOINTS THE FUNERAL HOME, AND ITS SUCCESSORS AND ASSIGNS, AS OUR ATTORNEY-IN-FACT, WHICH POWER OF
ATTORNEY IS IRREVOCABLE AND IS COUPLED WITH AN INTEREST TO ACT FOR US WITH FULL POWER TO MAKE COLLECTION OF, COMPROMISE, SETTLE
AND TO ENDORSE OR RECEIPT IN MY(OUR) NAME(S), OR OTHERWISE, ANY CHECK, DRAFT, RECEIPT OR RELEASE FOR THE PROCEEDS OF SAID
POLICY(IES) AS FULLY TO ALL INTENTS AND PURPOSES AS WE OURSELVES COULD DO, HEREBY RATIFYING AND CONFIRMING ALL THAT OUR SAID
ATTORNEY MAY DO OR CAUSE TO BE DONE BY VIRTUE HEREOF. THE UNDERSIGNED ALSO AUTHORIZES AND DIRECTS ANY ORGANIZATION, AGENCY,
ENTITY, OR PERSON TO GIVE AND RELEASE ANY AND ALL INFORMATION REGARDING THE POLICY(IES) TO THE FUNERAL HOME, ITS/HIS SUCCESSORS
AND ASSIGNS, OR ANYONE ACTING ON THEIR BEHALF. THE UNDERSIGNED GRANT TO THE FUNERAL HOME, AND ANY OF ITS/HIS SUCCESSORS AND
ASSIGNS, PERMISSION TO OBTAIN ALL PRIVACY ACT AND FREEDOM OF INFORMATION ACT INFORMATION REQUESTED BY THEM TO PROCESS ALL
INSURANCE CLAIMS HEREUNDER. THE UNDERSIGNED CERTIFY THAT THEY ARE EACH OVER THE AGE OF EIGHTEEN (18) YEARS AND NOT UNDER A
LEGAL INCAPACITY. THIS ASSIGNMENT WILL BE INTERPRETED UNDER VIRGINIA LAW. THE EXCLUSIVE JURISDICTION AND VENUE FOR LEGAL
PROCEEDINGS HEREUNDER IS PORTSMOUTH, VIRGINIA. THE ASSIGNEE(S) SHALL BE ENTITLED TO COLLECT THEIR COSTS (INCLUDING ATTORNEY
FEES OF 33 1/3%) AND INTEREST (@ THE RATE OF 18% PER ANNUM) IN ENFORCING THIS ASSIGNMENT.
IN WITNESS WHEREOF, I(WE) HAVE SET OUR HAND(S) AND SEAL(S) AT
_________________________________________________
(CITY AND STATE)
THIS ______ DAY OF ________________________(MONTH), __________ (YEAR):
________________________________________________
ST
(SIGNATURE OF 1 BENEFICIARY)
STATE/DISTRICT OF
CITY/COUNTY OF
I,
________________________________________________
_________________________________
(SIGNATURE OF 2ND BENEFICIARY)
___________________________________
______________________________________, A NOTARY PUBLIC IN AND FOR THE CITY/COUNTY AND STATE/DISTRICT AFORESAID, DO
HEREBY CERTIFY THAT
_________________________________________PERSONALLY APPEARED BEFORE ME THIS _________ DAY OF
_______________(MONTH), _______ (YEAR),
AND, AFTER HAVING BEEN DULY SWORN, ACKNOWLEDGED AND AFFIRMED THE FOREGOING
ASSIGNMENT.
__________________________________________________________
MY COMMISSION EXPIRES: ____________________________________
(NOTARY PUBLIC)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY TO
BETA CAPITAL CORP.
FOR VALUE RECEIVED, THE UNDERSIGNED DOES HEREBY IRREVOCABLY ASSIGN, TRANSFER, CONVEY AND SET OVER UNTO BETA CAPITAL CORP., AND THEIR
RESPECTIVE SUCCESSORS AND ASSIGNS (COLLECTIVELY, “ASSIGNEES”), ALL OF ITS/HIS RIGHTS, TITLE, INTEREST AND CLAIMS IN AND TO THE WITHIN ASSIGNMENT,
AND DIRECT THAT PAYMENT ON THE POLICY IES BE MADE TO BETA CAPITAL CORP AT THE ADDRESS BELOW. THE UNDERSIGNED
APPOINTS BETA CAPITAL CORP., AND THEIR RESPECTIVE SUCCESSORS AND ASSIGNS, AS ITS/HIS ATTORNEYS-IN-FACT, WHICH POWER OF ATTORNEY IS IRREVOCABLE
AND COUPLED WITH AN INTEREST, TO ACT FOR IT/HIM WITH FULL POWER TO MAKE COLLECTION OF, COMPROMISE, SETTLE, AND TO ENDORSE OR RECEIVE IN THE NAME
OF THE UNDERSIGNED, ANY CHECK, DRAFT, RECEIPT, OR RELEASE FOR THE PROCEEDS OF THE POLICY(IES), AS FULLY TO ALL INTENTS AND PURPOSES AS THE
UNDERSIGNED, HEREBY RATIFYING, CONFIRMING AND APPROVING ANYTHING THAT SAID ATTORNEYS MAY DO OR CAUSE TO BE DONE BY VIRTUE HEREOF. THIS POWER
OF ATTORNEY SHALL BE IRREVOCABLE, AND COUPLED WITH AN INTEREST. IN THE EVENT THAT ANY PAYMENTS OF PROCEEDS ARE MADE BY THE INSURANCE
COMPANY, OR ITS AGENT, TO THE UNDERSIGNED, ERRONEOUSLY, SUBSEQUENT TO THE EXECUTION OF THIS REASSIGNMENT TO ASSIGNEES, THEN THE UNDERSIGNED
AGREES TO HOLD THE PROCEEDS IN TRUST AND TO IMMEDIATELY PAY THE PROCEEDS TO ASSIGNEES AS HEREIN PROVIDED. THE UNDERSIGNED CERTIFIES THAT THE
PERSON(S) SO NAMED ABOVE IS/ARE THE CORRECT INSURANCE CONTRACT BENEFICIARY(IES), AND THAT THE BENEFICIARY(IES) IS/ARE EIGHTEEN (18) YEARS OF AGE
OR OLDER AND ARE NOT UNDER A LEGAL INCAPACITY. THIS ASSIGNMENT WILL BE INTERPRETED UNDER VIRGINIA LAW. EXCLUSIVE JURISDICTION AND VENUE FOR
LEGAL PROCEEDINGS HEREUNDER IS PORTSMOUTH, VIRGINIA. THE ASSIGNEE(S) SHALL BE ENTITLED TO COLLECT ITS COSTS (INCLUDING ATTORNEY FEES OF 33
1/3%) AND INTEREST (@ THE RATE OF 18% PER ANNUM) IN ENFORCING THIS ASSIGNMENT.
(
STATE/DISTRICT OF
CITY/COUNTY OF
I,
)
.
__________________________________ (Name of funeral home)
_________________________
BY:
___________________________
__________________________________________________________
AUTHORIZED SIGNATORY FOR FUNERAL HOME
_____________________________________________ , A NOTARY PUBLIC IN AND FOR THE CITY/COUNTY AND STATE/DISTRICT AFORESAID,
_________________________________________________, PERSONALLY APPEARED BEFORE ME THIS _______ DAY
_______________ (MONTH), ________ (YEAR), IN PERSON, AND AFTER HAVING BEEN DULY SWORN, ACKNOWLEDGED AND AFFIRMED THE
FOREGOING REASSIGNMENT ON BEHALF OF THE FUNERAL HOME.
DO HEREBY CERTIFY THAT
OF
__________________________________________________________
(NOTARY PUBLIC)
MY COMMISSION EXPIRES:
____________________________________
BETA CAPITAL CORP. 4007 SEABOARD COURT, SUITE 1, PORTSMOUTH, VA 23701
TELEPHONE:
(757) 488-6960
TOLL FREE:
(800) 430-7935
FAX:
(877) 375-9118
WWW.BETACAPITALCORP.COM