Name: _____________________                             for is: ______

Life Policy No. __________________

I do hereby grant, transfer and assign absolutely for valuable consideration all my right, title and interest in the within policy and the sum thereby assured to the _____  of _____, _____ and their assigns and declare that _____ bank  of _____, _____ will henceforth hold the within policy as absolute owner thereof and that the receipt or receipts of the said _____ bank  of _____, or their assigns for any sum or sums of money to be received by them under or on account of the said policy shall discharge the life _____, ________ Office from all responsibility in respect of the application of such money as effectually and to all intents and purposes as if such receipt or receipts were signed by myself, my heirs, my executors or administrators.

Dated at________________________________

This ____________________________day of ______________________

Signature