{Company Name} - wrli.com

1 Administrative Office: Box 305014, Nashville, TN 37230-5014 Insurance Services 866-215-5343 RELEASE OF assignment OF LIFE INSURANCE POLICY Insured: Policy No.: Dated: Date assigned: Assigned To: The undersigned, Assignee under the above policy, hereby relinquishes all interest in the above referenced policy by virtue of the aforesaid assignment which is hereby released and cancelled. Executed and Witnessed this _____ day of _____ Witnesses (two required) Signature: (Print Name) Signature: (Print Name) Assignee(s) Executed By: Title: Address: City: State: Zip: Notary Jurat State of:_____ County of: _____ On this _____day of _____ before me personally came.

2 To me, known to be the individual(s) described in and who executed this assignment and such individual(s) acknowledged to me and in my presence and executed this assignment for the purpose therein stated. My term of office expires: _____ The Company, in accordance with its rules, has retained the duplicate of this instrument. Page 1 of 1 L-513 Rev. 05-16-09