Exhibit 4
Form of Assumption Certificate
1061
AMERITAS VARIABLE LIFE INSURANCE COMPANY
0000 "X" Xxxxxx
Xxxxxxx, Xxxxxxxx 00000
CERTIFICATE OF ASSUMPTION
Ameritas Variable Life Insurance Company ("Ameritas") is a party to
an Agreement between Acacia National Life Insurance Company ("Acacia") and
Ameritas. The Agreement provides for the assumption by Ameritas of all
obligations, liabilities, and rights under certain policies issued by Acacia. By
virtue of this Agreement, such policies of insurance issued by Acacia are now
directly those of Ameritas.
In all other respects, the terms, conditions, and provisions of the
Policy to which this Certificate is to be attached (the "Policy") shall remain
in full force and effect.
All premiums due on the Policy are now payable to Ameritas.
Subsequent premium payments made to Ameritas shall release Acacia from any and
all liability under the Policy which may arise on or after the effective date of
this Certificate.
The policyowner(s) has given consent to this transaction by either:
1) acceptance by ballot, 2) payment of premium, or 3) by failing to send written
notice of rejection to Ameritas or Acacia within the time period specified by
law.
This Certificate is to be attached to and will form a part of the
Policy, as identified in this Certificate.
Acacia Policy No.: ______________________________
Policyowner: ___________________________________
The policy number of your policy with Ameritas will be Policy No.: _____________
IN WITNESS WHEREOF, Ameritas has caused this Certificate of Assumption to be
executed effective __________________.
AMERITAS VARIABLE LIFE INSURANCE COMPANY
/s/ Xxxxxxxx X. Xxxx
Printed Name: Xxxxxxxx X. Xxxx
Title: Chief Executive Officer
