Assignment Form
Important Notice:
- In order to ensure the accuracy of processing your Assignment Form, please clearly state the Name of the Insured, the Social Security Number and the Account Number of the Insured along with the Name and address of the Assignee. Any Assignment designated herein will be for all Certificate/Notice(s) of Insurance unless otherwise noted.
- If a Beneficiary has been designated to receive the benefits payable upon death of the Insured, the Insured should, before making the Assignment, execute and submit to the Plan Agent a beneficiary change form to the effect of replacing the designated Beneficiary by the estate of the Insured.
- The Insured should submit the completed Assignment to the Plan Agent. After recording, a photocopy will be returned to the Insured. The Insured should send a copy to the Assignee and attach a copy to the Insured's Certificate of Insurance.
- To avoid complications upon death of the Insured, it is advisable that the ASSIGNEE, immediately after the Assignment has been made, MAKE A BENEFICIARY DESIGNATION naming the person(s) entitled to receive the benefits payable upon death of the Insured. The beneficiary designation form SHOULD BE DATED THE DAY AFTER the assignment is completed and dated. The Assignee may designate himself as a Beneficiary. Provision should also be made for a contingent Beneficiary to whom such benefits would be payable in the event that the primary Beneficiary predeceases the Insured. You may designate a trustee as beneficiary by:
- Indicating " see attached" on the Beneficiary Form;
- Completing one of the two trustee designations in Addendum A; and
- Attaching Addendum A to the Beneficiary Designation Form.
- The Insured transfers ownership by completing the Assignment of Group Insurance Form. The new owner then designates a beneficiary.
- When naming an INDIVIDUAL as assignee (GIFT ASSIGNMENT), please indicate his/her name and complete mailing address.
- When naming a TRUST as assignee (GIFT ASSIGNMENT), you must include the name and address of the trustee(s), the title of the trust and the date of the execution.
- When naming a COMPANY as assignee (VALUE ASSIGNMENT), please provide the company's complete name and mailing address.
- Please note that the CPA is the PARTICIPANT OWNER of the SPOUSE POLICY. Therefore, the participant's signature is required on the ASSIGNMENT OF GROUP INSURANCE form.
- You must also provide us with the assignee's social security number or a taxpayer identification number, whichever may apply. Failure to provide this information will delay your request.
- Upon death of the Assignee, his rights will pass to his estate, unless other arrangements have been made. In the absence of such arrangements, the Assignee should consider the advisability of having a will in existence at the time of his death containing specific directions to his executor on how to dispose of the estate's rights in the insurance covered by the Assignment.
- If you are unsure as to how to describe your beneficiary designation you will need to contact your personal attorney.
- Please contact the Customer Service Department at 1-800-223-7473 if you have any questions.
- Please complete the form.
- Print, sign, and return the form to:
Aon Insurance Services, Plan Agent
AICPA Insurance Trust, 159 E. County Line Road, Hatboro, PA 19040-1218
Fax: 800-242-7248
HAVING THE INTENTION TO MAKE A GIFT, the undersigned Insured,
(First Name)
(Last Name)
being of legal age, hereby assigns, transfers and sets over unto the Assignee
(First Name)
(Last Name) whose address is
(Street)
(City)
(State)
(Zip Code) all of his right, title, claim, interest, benefits,
and all other incidents of ownership of whatever nature, which he
now has or hereafter may have in and to the insurance under group
Policy No.(s)
issued by
THE PRUDENTIAL INSURANCE COMPANY OF
AMERICA
(hereinafter referred to as the Company)
in accordance with the terms and conditions of said policy(ies) or as may be allowed by the Company, which insurance is evidence by Certificate No.(s)/Policy No.(s) or any certificate or certificates hereafter issued in connection with such insurance. Without limiting in any way the generality of the foregoing, the Assignment shall vest in the Assignee the right to designate a Beneficiary, to receive disability benefits (if applicable) or to exercise any conversion privilege provided under said Policy(ies) under which the Insured, in the absence of this Assignment, could obtain an individual policy of life insurance, and the Insured hereby agrees to execute any and all documents and take any and all actions which the Assignee or the Company may request in order for the Assignee to exercise such conversion privilege.
(hereinafter referred to as the Company)
in accordance with the terms and conditions of said policy(ies) or as may be allowed by the Company, which insurance is evidence by Certificate No.(s)/Policy No.(s) or any certificate or certificates hereafter issued in connection with such insurance. Without limiting in any way the generality of the foregoing, the Assignment shall vest in the Assignee the right to designate a Beneficiary, to receive disability benefits (if applicable) or to exercise any conversion privilege provided under said Policy(ies) under which the Insured, in the absence of this Assignment, could obtain an individual policy of life insurance, and the Insured hereby agrees to execute any and all documents and take any and all actions which the Assignee or the Company may request in order for the Assignee to exercise such conversion privilege.
In witness whereof I have hereunto set my hand and seal,
this ________ day of _______________, 20______.
X___________________________________(Witness to Signature of CPA Participant)
X___________________________________(Signature of CPA Participant)
Please complete below:
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The Company assumes no obligations as to the validity
or sufficiency of this Assignment, and does not pass upon its legality.
If payment is being made to any trustee of a trust entitled to collect
any benefits provided under said Policy(ies), the Company may assume
that such trustee is acting in such fiduciary capacity until notice
in writing to the contrary is received by the Company at a Home Office,
and any payment made to such trustee prior to receipt of such notice
shall discharge the Company from all liability as to such payment.
The Company agrees that a recording and filing of
this Assignment in the manner hereinafter indicated shall, as to the
insurance thereby assigned, constitute the Company's waiver of a provision,
if any, contained in said Policy(ies) otherwise prohibiting such assignment.
_________________________________(Recorded and filed at: Hatboro, Pennsylvania)
_________________________________(Aon Insurance Services Plan Agent)
_________________________, 20_____(Date)
_________________________________ (Authorized Signature of Plan Agent)
Important Notes:
A copy of the endorsement of the Beneficiary Provision/Change of Legal Name as prepared by the Insurance Company will be forwarded to you for attachment to the Certificate or Notice(s) of Insurance in your Possession. Do not send the Certificate or Notice(s) with this form.
A Beneficiary designated herein shall be entitled to payment only if he or she is living at the death of the Insured and if there is not then living a Beneficiary designated in a higher priority. Two or more Beneficiaries in the same priority class shall be entitled to payment in separate shares as indicated. If no Beneficiary designated herein is living at the death of the Insured, the proceeds shall be payable in one sum to the estate of the Insured or if the insurance has been assigned to a natural individual, to such assignee, if living, otherwise to the estate of the assignee.
The Company in determining the existence, identity, age or any other facts related to person designated as Beneficiaries herein, either as a class or otherwise, may rely solely on any affidavit or other evidence deemed satisfactory by it, and any payment made by the Company in reliance thereon shall to the extent of such payment be a valid discharge of the Company's obligation under the Policy.
The proceeds referred to herein shall be the aggregate of the amount payable in accordance with the Life Insurance portion of this policy and the amount, if any, becoming payable in accordance with the Accidental Death and Dismemberment portion of the Policy.
ASSIGNEE DESIGNATION
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA (hereafter referred to as the Company) is hereby requested to change the Certificate/Notice(s) of Insurance Number(s)
as follows.
If the Policy(ies) mature(s) by death, the proceeds then payable shall, subject to any facility of payment provision which may apply, be payable to the Beneficiary(ies), designated below:
Beneficiaries in Order of Priority:
Primary
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Name*
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Relationship to Insured
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DOB
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Contingent
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Name
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Relationship to Insured
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DOB
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%
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* If a Trust is named as a beneficiary, please include name of trustee.
Dated at _____________________this ______day of _____________,20_____
Signature of Assignee: X_______________________________________________
Witness: X_______________________________________________
ATTENTION: Please note that the signature of the Assignee must be witnessed by a disinterested party.
Addendum A
Trustee Designation (applies
only if a trust has been created in an executed trust agreement)
Name of Trustee(s):
Address:
Dated ________________executed by me and said Trustee(s).
Prudential assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its legality. In making payment to any Trustee(s), Prudential has the right to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by Prudential at its Group Life Claim office. If Prudential makes any payment(s) to the Trustee(s) before notice is received, Prudential will not have to make payment(s) again
Date: ________________________
_______, 20______
Signature of CPA Participant: :
X_____________________________________________
In cases where coverage has been assigned, signature of Assignee is required.
In cases where coverage has been assigned, signature of Assignee is required.
Witness: X____________________________________________
Trustee (Under Will) Designation (applies only if a trust has been set forth in your Will)
The trustee under any last Will and Testament of mine as shall be admitted to probate.
Prudential assumes no obligation as to validity or sufficiency of any executed Trust Agreement set forth in my Will and does not pass on its legality. In making payment to the trustee, Prudential has the right to assume that the trustee is acting in a fiduciary capacity until notice to the contrary is received by Prudential at its Group Life Claim office. If Prudential makes any payment(s) to the trustee before notice is received, Prudential will not have to make payment(s) again.
If for any reason no trustee under any such last Will and Testament shall be duly appointed, I hereby designate my estate as beneficiary. If Prudential makes any payment(s) in good faith to the legal representative of my estate, Prudential will not have to make payment(s) again.
Date: ________________________ _______, 20______
Signature of CPA Participant: : X_____________________________________________
In cases where coverage has
been assigned, signature of Assignee is required.
Witness: X____________________________________________
Plan Agent Use:
Date: 04-24-2024