American Capitol Assumption Agreement
Exhibit III.A.3.
Assumption Certificate
The American Capitol Assumption Certificate is attached hereto
and incorporated herein by reference.
AMERICAN CAPITOL INSURANCE COMPANY
POLICY NUMBER:
INSURED:
CERTIFICATE OF ASSUMPTION
This is to certify that AMERICAN CAPITOL INSURANCE COMPANY
("American Capitol"), a life insurance company organized and
existing under the laws of the State of Texas with offices in
Houston, Texas, has assumed and reinsured all of the contractual
obligations existing under the policy identified above heretofore
issued or assumed by STATESMAN NATIONAL LIFE INSURANCE COMPANY
("Statesman") in accordance with the terms and conditions thereof,
the same as if such policy had been originally issued with all its
terms, covenants, stipulations and provisions, by American Capitol.
This Certificate of Assumption is being issued in accordance with
the terms and conditions of an Assumption Agreement entered into
among American Capitol, the National Organization of Life and Health
Guaranty Associations and the Participating Guaranty Associations.
The Effective Date of this Certificate of Assumption is June 1,
1999.
Future payments of benefits and claims will be made by American
Capitol, and all premium payments, claims and correspondence
relating to the policy should be sent to:
Mailing Address Delivery Address
P. O. Box 42814 00000 Xxxxxxxx Xxxxxx, 0xx Xxxxx
Xxxxxxx, XX 00000-0000 Xxxxxxx, XX 00000
IN WITNESS WHEREOF, AMERICAN CAPITOL INSURANCE COMPANY has caused
this Certificate to be signed by its duly authorized officers as of
the effective date.
/s/H. Xxxxxxxx Xxxxxxxxxxx /s/Xxxx X. Xxxxxxx
--------------------------- ------------------------
H. Xxxxxxxx Xxxxxxxxxxx, Xxxx X. Xxxxxxx,
Secretary President
THIS CERTIFICATE BECOMES A PART OF YOUR POLICY AND SHOULD BE
ATTACHED THERETO.
ISSU###-##-####
