Prudential's Policyholder Remediation Plan letters:
Claim No.: Policy No.:
This Collateral Assignment is made in consideration for and as a condition to receiving an award providing a Policy Adjustment selected in the ADR Process of the Policyholder Remediation Plan regarding the above Claim (the "Award"). This acknowledges that once adjustments are made to the price of the above policy, such adjustments may be recovered from the policy, as explained below. This assignment acknowledges that in return for the Company adjusting the price of the policy the Company has a priority interest in certain policy rights and values.
I/WE HEREBY ASSIGN, GRANT AND TRANSFER AS COLLATERAL TO THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, 751 Broad Street, Newark, New Jersey, or its insurance subsidiaries, successors and assigns ("Prudential"), a first lien priority interest in the following rights, benefits and privileges in the above Policy to secure and obtain repayment to Prudential of the full amount of premium otherwise payable on the policy that is adjusted, now and hereafter (the Premium Price Adjustment), as provided under the Award:
1. The right to collect and receive out of the cash surrender value of the Policy the amount of premium price adjustment provided under the Award.
This right may be exercised on one or more occasions only in connection with and prior to the occurrence of any loan, withdrawal or surrender of any type concerning the Policy. The cash surrender value includes but is not limited to, the policy's guaranteed cash value, loan value, dividends and dividend credits, paid-up additions, investment distributions, and other additions to the Policy.
2. The right to collect and receive upon the death of the insured or Policy maturity and amount of premium price adjustment provided under the Award.
This right may be exercised only with respect to any value in the Policy beyond the face amount and policy rider death benefits as of the Policy effective date, less any existing Policy loan debt.
3. The right to change the policy's dividend option, if applicable, and mode of payment.
4. The Policy may be modified only with the consent of Prudential.
Every person who has an ownership interest in the Policy has signed this Collateral Assignment, and shall cooperate in maintaining the interests assigned under this Collateral Assignment.
Policyholder Signature Date Co-Policyholder Signature Date
Additional Co-Policyholder(s) and parties with ownership interest(s):
Signature Date Signature Date