IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY

IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY
(To Funeral Home/Cemetery)
Insurance Company:
Deceased/Insured:
Policy #:
SSN:
Date of Birth:

MonthDayYear
Date
Date of Death:

MonthDayYear
Date
Deceased Address:
Cause of Death:
Beneficiary(s) Name
Address, City, State, Zip
Social Security #
Total Amount Assigned
Funeral Home and/or Cemetery Name
City and State
Contact Person
Phone Number
Fax Number
E mail Address
example@example.com
This Irrevocable Assignment is made on ( / ), 20( ), between Beneficiary(s) above and the Funeral Home/Cemetery above, in consideration for (i) the Funeral

Home/Cemetery providing services in the burial of the above Deceased/Insured, said services having been requested and accepted by Beneficiary(s) and/or (ii) the funds that have been advanced and paid to the Funeral Home/Cemetery and/or the Beneficiary(s) by Summit Capital LLC related to such services. The undersigned irrevocably assigns, transfers and sets over to the Funeral Home/Cemetery, its successors and assigns, the above described policy(s) of life insurance represented by the Total Assignment Amount, plus statutory interest from deceased’s date of death until claim paid, any unearned policy premiums and any supplementary contracts issued in connection therewith (collectively the “Policy” This Assignment includes all claims, options, privileges, rights, title and interest therein and thereunder, subject to all terms and conditions of the Policy. Beneficiary(s) hereby guarantees the validity and sufficiency of the foregoing irrevocable assignment to the Funeral Home/Cemetery, and Beneficiary(s) further guarantees to warrant title to the Policy(s) and defend the Funeral Home/Cemetery against any claims on the Policy(s Beneficiary(s) hereby irrevocably authorizes the above referenced Insurance Company to make payment of the Total Amount Assigned above, plus statutory interest and unearned policy premiums to the Funeral Home/Cemetery. Beneficiary(s) hereby irrevocably authorizes said Insurance Company to give Funeral Home/ Cemetery any information that it may require regarding said Policy(s Beneficiary(s) hereby appoints the Funeral Home/Cemetery as their Attorney-in-Fact and to act on their behalf with regard to the collection of, settlement of, and receipt of proceeds of said Policy(s) or certificate(s), including but not limited to, giving the Funeral Home/Cemetery the right to endorse checks and claimant statement forms in Deceased/Insured/Beneficiary(s) name. If, for any reason, the Funeral Home/ Cemetery does not receive full payment within 90 days I agree to immediately pay the Funeral Home/Cemetery the amount of its loss on the assignment. If for any reason it becomes necessary for the Funeral Home/Cemetery to precede against me, I understand that I am liable for all costs of collections, including but not limited to, reasonable attorneys’ fees and court costs. I agree that the exclusive jurisdiction for legal proceedings hereunder is Arkansas. In the event the Policy(s) is not enclosed, I certify that the Policy(s) has been lost or destroyed.
1st Beneficiary's Signature

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2nd Beneficiary's Signature

Clear
Relationship to Deceased
3rd Beneficiary's Signature

Clear
Relationship to Deceased
4th Beneficiary's Signature

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commissioned and acting, the within named Representative, to me personally known or properly identified, who stated that he had so signed, executed and delivered the foregoing instrument for the consideration and purposes therein mentioned and set forth.

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personally appeared before the undersigned, a Notary Public, duly qualified,
Notary Stamp or Seal
Notary Public Signature Date
Date

MonthDayYear
Date
Commission Expires Notary Stamp or Seal
Commission Expires
IRREVOCABLE RE-ASSIGNMENT AND POWER OF ATTORNEY
(To Summit Capital, LLC)
Funeral Home and/or Cemetery Name:
Address, City, State, Zip:
Insurance Company Name:
Insurance Policy Number:
TO: Summit Capital LLC, PO BOX 8589, Springdale, AR, 72766-8589
Funeral Cost:
Processing Fee:
Total Amount Assigned:
The undersigned representative and funeral home or cemetery named above (collectively “the Funeral Home”) irrevocably re-assigns, transfers and sets over to Summit Capital LLC, PO BOX 8589 Springdale, AR 72766-8589, its successors and assigns, all of its rights, privileges and

interest in that certain Irrevocable Assignment dated ( / ), 20( ), by which the Funeral Home is an assignee of certain insurance Policy(s), a

copy of which irrevocable assignment is attached hereto and incorporated herein (the “Assignment” The undersigned further appoints Summit Capital LLC to act as its Attorney-in-Fact with regard to the collection of, settlement of, and receipt of the proceeds of said Policy(s) or certificate(s) noted in said Assignment, including but not limited to, the right to endorse checks. Any payment made by Summit Capital LLC to the Funeral Home pursuant to this Re-Assignment agreement is subject to Summit Capital LLC’s verification and satisfaction that said Policy(s) are valid, accurate and payable to Summit Capital LLC. The Funeral Home hereby authorizes the insurance company identified in the Assignment to issue a check(s) directly to Summit Capital LLC. In the event that any payment of Policy proceeds is made by said insurance company, its agent or the Beneficiary(s) to the Funeral Home, the Funeral Home agrees to hold the proceeds in trust and to immediately pay the proceeds to Summit Capital LLC within ten (10) days, without necessity of any notice or request to so pay the funds to Summit Capital LLC. The Funeral Home further agrees that upon request by either Summit Capital LLC or said insurance company the Funeral Home will promptly provide all documents, material or information identified and needed to process a claim on the forgoing Policy(s The undersigned agrees that the exclusive jurisdiction and venue for legal proceeding hereunder is in Arkansas.
PH
FAX
Signature of Funeral Home/Cemetery Authorized Representative and Title

Name of Funeral Home/Cemetery

On this day, qualified, commissioned and acting, the within named Representative, to me personally known or properly identified, who stated that he had so signed, executed and delivered the foregoing instrument for the consideration and purposes therein mentioned and set forth.

personally appeared before the undersigned, a Notary Public, duly
Notary Public Signature

Clear
Date

MonthDayYear
Date
Notary Stamp or Seal
Commission Expires Notary Stamp or Seal
Commission Expires
Should be Empty:

IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY

(To Funeral Home/Cemetery)

IRREVOCABLE RE-ASSIGNMENT AND POWER OF ATTORNEY

(To Summit Capital, LLC)

TO: Summit Capital LLC, PO BOX 8589, Springdale, AR, 72766-8589