IRREVOCABLE ASSIGNMENT FORM

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Important Notes:

1) The Policy Owner cannot assign benefits unless they are receiving aid. It may not be in the customer’s best interest to have them give up their rights to the policy.

2) The Policy Owner must understand that they will have no rights over the insurance policy once they sign this document

3) You will be required to upload a form of identification (Texas Driver’s License, Texas Identification Card, U.S. Passport). If you do not have one of the acceptable forms of identification, please wait until you have them before proceeding with this Sign-Up process.

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Policy Owner Name

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Policy Owner Email

example@example.com

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Policy Owner City

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Insured or Annuitant Name

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Policy/Contract Number

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Upload a Photo or Copy of Your IdentificationAcceptable forms of identification are a valid Texas Driver’s License, Texas Identification Card, and a US Passport.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Sign Document* This field is required.

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Date

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What Happens Next?

Please allow (3) business days for the processing of this request.

Your requested change will not become effective until the request is received and recorded at the home office of Texas Service Life Insurance Company.

Click “SUBMIT” below to complete form submission.

If you have any questions about this paperwork, please call us at 800-756-7306 and ask for Customer Service or email customerservice@tslic.com and we will be happy to answer any questions you might have.

P.O. BOX 341899, AUSTIN, TEXAS 78734∙PH (800) 756-7306∙FAX (512) 263-6981∙EMAIL: CUSTOMERSERVICE@TSLIC.COM