Assignment Of Life Insurance Proceeds Form
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Assignment of Life Insurance Proceeds
I, ___________________________, hereby state that I am the beneficiary under insurance Policy number
__________________________ issued by ______________________________________________ on the life of
_______________________________________________, now deceased and further state that I am entitled to
receive the death benefit of __________________________ payable under said policy.
In consideration of merchandise furnished, services rendered and other expenses requested by me and
incurred
in
connection
with
the
funeral,
preparation,
burial
and
final
expenses
of
__________________________________________, I hereby assign and transfer to Colonial – Wojciechowski
Funeral Home located at 8025 W. Golf Road, Niles, Illinois 60714 the proceeds of said policy to extent of
$__________________, and request and direct that payment of said sum be paid to said funeral home and the
balance to me; and hereby appoint said funeral director my attorney with power and authority to do all things
necessary to carry out this assignment as fully as I might do in person.
In consideration of its compliance with my request and direction, I hereby release the above mentioned
insurance company from any and all liability with respect to any amount paid to said funeral director and agree
that payment in accordance with this request shall fully discharge said insurance company with respect to any
amount paid.
This instrument shall be binding upon me, my executors, administrators, heirs and assigns forever.
____________________________________
____________________________________
Signature of beneficiary
Printed name of beneficiary
State of Illinois
County of Cook
I, ________________________________, a Notary Public in and for said County and State, do hereby certify
that_________________________________________ personally known to me to be the same person whose name is
subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that ______ signed, sealed
and delivered the said instrument as a free and voluntary act, for the purposed therein set forth.
Given under my hand and notarial seal this ____________
day_____________________________ in the year _________.
________________________________________________________
Notary Public
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